Provider Demographics
NPI:1023342474
Name:GREAT LAKES PEDIATRIC ASSOCIATES
Entity type:Organization
Organization Name:GREAT LAKES PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ILEEN
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-887-3000
Mailing Address - Street 1:3400 PINETREE RD
Mailing Address - Street 2:STE 102
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4286
Mailing Address - Country:US
Mailing Address - Phone:517-887-3000
Mailing Address - Fax:
Practice Address - Street 1:3400 PINETREE RD
Practice Address - Street 2:STE 102
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4286
Practice Address - Country:US
Practice Address - Phone:517-887-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063626208000000X
MI4301078945208000000X
MI4301086445208000000X
MI4301049233208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3069367Medicaid
MI3080275Medicaid
MI4366885Medicaid
MI1144338443OtherNPI
MI1144338450OtherNPI
MI1730297045OtherNPI
MI1831309921OtherNPI