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NPI Code Detail

MEDICARE: LAKES OBGYN SPECIALIST

MEDICARE: LAKES OBGYN SPECIALIST
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
1363L00000XNurse Practitioner
2363A00000XPhysician Assistant
3367A00000XAdvanced Practice Midwife
4207V00000XObstetrics & Gynecology Physician

General Provider Information

NPI Number : 1548570062
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKES OBGYN SPECIALIST
Provider Business Mailing Address
First Line : PO BOX 776982
Second Line :
City : CHICAGO
State : IL
Zip : 60677-6982
Country : US
Telephone Number : 800-494-5797
Fax Number :
Provider Business Practice Location Address
First Line : 6401 PRAIRIE ST STE 1700
Second Line :
City : NORTON SHORES
State : MI
Zip : 49444-7843
Country : US
Telephone Number : 231-672-7939
Fax Number :
Authorized Official
Title or Position : CHIEF FINANCIAL OFFICE
Name : MICHAEL GUSHO
Credential :
Telephone Number : 734-398-0642
Provider Enumeration Date : 10/18/2010
Last Update Date : 03/05/2026

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Directions to “LAKES OBGYN SPECIALIST ” Practice Location

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