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General NPI Number Information
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NPI Number | 1720095417
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Entity Type | Organization
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Legal Business Name | GREAT LAKES DIALYSIS, L.L.C.
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Dates
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Enumeration Date | 08/02/2006
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Last Update Date | 04/07/2025
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Provider Practice Location Address
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Address Line | 14614 KERCHEVAL ST
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City | DETROIT
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State | MI
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Zip | 48215-2814
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Country | US
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Telephone | 313-308-4200
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Fax | 313-332-0334
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Provider Business Mailing Address
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Address Line | PO BOX 428
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City | LOCKPORT
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State | IL
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Zip | 60441-6428
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Country | US
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Telephone | 815-714-7170
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Fax | 630-672-4980
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL / CMO
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Name | MORUFU OLATUNJI ALAUSA
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Credential | MD
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Telephone | 815-741-6830
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | 4301072901
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License Number State | MI
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