MEDICARE: GREAT LAKES HOME DOCTORS PC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1679705354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES HOME DOCTORS PC

Provider Business Mailing Address
First Line	:	1160 VILLA CT N
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3376
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1160 VILLA CT N
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3376
Country	:	US
Telephone Number	:	313-978-2343
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. AUNDREY LUTSKOVSKY
Credential	:	D.O.
Telephone Number	:	313-978-2343

Provider Enumeration Date	:	08/14/2009
Last Update Date	:	04/15/2011

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