MEDICARE: GREAT LAKES PHYSICIANS LLC

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	363LP2300X	Primary Care Nurse Practitioner
2	363AM0700X	Medical Physician Assistant

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

General Provider Information

NPI Number	:	1598742801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES PHYSICIANS LLC

Provider Business Mailing Address
First Line	:	6681 RIDGE ROAD
Second Line	:	SUITE 300
City	:	PARMA
State	:	OH
Zip	:	44129-5713
Country	:	US
Telephone Number	:	216-398-0863
Fax Number	:	216-351-3619

Provider Business Practice Location Address
First Line	:	6681 RIDGE ROAD
Second Line	:	SUITE 300
City	:	PARMA
State	:	OH
Zip	:	44129-5713
Country	:	US
Telephone Number	:	216-398-0863
Fax Number	:	216-351-3619

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. JAMES SAGHAFI
Credential	:
Telephone Number	:	216-702-0360

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	04/30/2008

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