MEDICARE: GREAT LAKES BAY HEALTH CENTERS

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	261QF0400X	Federally Qualified Health Center (FQHC)		MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0G36111	OTHER	MI	0G36111 MEDICARE PAY BILL TO

General Provider Information

NPI Number	:	1710181128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES BAY HEALTH CENTERS

Provider Business Mailing Address
First Line	:	501 LAPEER
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48607
Country	:	US
Telephone Number	:	989-759-6464
Fax Number	:	989-399-8233

Provider Business Practice Location Address
First Line	:	6800 NEWARK RD
Second Line	:	SUITE 200
City	:	IMLAY CITY
State	:	MI
Zip	:	48444-9656
Country	:	US
Telephone Number	:	810-724-3201
Fax Number	:	810-724-4605

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	LISA GALONSKA
Credential	:
Telephone Number	:	989-759-6464

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	09/19/2016

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1831561182 — GREAT LAKES BAY HEALTH CENTERS
Practice Location Address:

6800 NEWARK RD
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48444-9656

Practice Phone: 810-724-3201
Practice Fax: 810-724-4605

Directions to “GREAT LAKES BAY HEALTH CENTERS ” Practice Location

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