Healthcare Provider Details

I. General information

NPI: 1174058549
Provider Name (Legal Business Name): GREAT LAKES LOCUMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 ELMWOOD AVE
KENMORE NY
14217-1304
US

IV. Provider business mailing address

13 VISCOUNT DR
WILLIAMSVILLE NY
14221-1766
US

V. Phone/Fax

Practice location:
  • Phone: 716-447-6100
  • Fax:
Mailing address:
  • Phone: 716-863-2454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MIAN MAJEED
Title or Position: OWNER
Credential: M.D.
Phone: 716-863-2454