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General NPI Number Information
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NPI Number | 1295171650
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Entity Type | Organization
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Legal Business Name | GREAT LAKES MEDICAL, P.C.
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Dates
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Enumeration Date | 05/13/2013
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Last Update Date | 07/15/2013
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Provider Practice Location Address
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Address Line | 5511 W US HIGHWAY 10 SUITE A
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City | LUDINGTON
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State | MI
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Zip | 49431-2455
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Country | US
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Telephone | 231-843-1553
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Fax |
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Provider Business Mailing Address
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Address Line | 5511 W US HIGHWAY 10 SUITE A
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City | LUDINGTON
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State | MI
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Zip | 49431-2455
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Country | US
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Telephone | 231-843-1553
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD WAYNE MACAULEY
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Credential | MEDICAL DOCTOR
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Telephone | 517-449-2452
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 04411G
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License Number State | MI
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