MEDICARE: GREAT LAKES PODIATRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier	5901001228	MI
2	332B00000X	Durable Medical Equipment & Medical Supplies	5901001228	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043728553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES PODIATRY PLLC

Provider Business Mailing Address
First Line	:	W4042 LAKE MARY DR S
Second Line	:
City	:	VULCAN
State	:	MI
Zip	:	49892-8452
Country	:	US
Telephone Number	:	906-280-5396
Fax Number	:

Provider Business Practice Location Address
First Line	:	126 S 25TH ST STE A
Second Line	:
City	:	ESCANABA
State	:	MI
Zip	:	49829-1364
Country	:	US
Telephone Number	:	906-786-2385
Fax Number	:	877-276-3960

Authorized Official
Title or Position	:	OWNER/PODIATRIST
Name	:	DENNIS W LEVEILLE
Credential	:	DPM
Telephone Number	:	906-786-2385

Provider Enumeration Date	:	01/18/2018
Last Update Date	:	03/12/2026

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Directions to “GREAT LAKES PODIATRY PLLC ” Practice Location

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