Healthcare Provider Details

I. General information

NPI: 1598742801
Provider Name (Legal Business Name): GREAT LAKES PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6681 RIDGE ROAD SUITE 300
PARMA OH
44129-5713
US

IV. Provider business mailing address

6681 RIDGE ROAD SUITE 300
PARMA OH
44129-5713
US

V. Phone/Fax

Practice location:
  • Phone: 216-398-0863
  • Fax: 216-351-3619
Mailing address:
  • Phone: 216-398-0863
  • Fax: 216-351-3619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES SAGHAFI
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 216-702-0360