MEDICARE: GREAT LAKES MEDICAL EQUIPMENT GROUP

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	332B00000X	Durable Medical Equipment & Medical Supplies		MI

General Provider Information

NPI Number	:	1679973408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES MEDICAL EQUIPMENT GROUP

Provider Business Mailing Address
First Line	:	6940 DIXIE HWY
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9760
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6940 DIXIE HWY
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9760
Country	:	US
Telephone Number	:	989-892-7722
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	SEHRISH KHURRAM
Credential	:
Telephone Number	:	989-892-7722

Provider Enumeration Date	:	08/29/2014
Last Update Date	:	08/29/2014

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