Provider Demographics
NPI:1063203859
Name:GREAT LAKES UROLOGY PLLC
Entity type:Organization
Organization Name:GREAT LAKES UROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:K
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:CHEVLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-844-5600
Mailing Address - Street 1:3085 HARLEM RD STE 350
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-2591
Mailing Address - Country:US
Mailing Address - Phone:716-844-5600
Mailing Address - Fax:168-445-7507
Practice Address - Street 1:3085 HARLEM RD STE 200
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-2591
Practice Address - Country:US
Practice Address - Phone:716-844-5000
Practice Address - Fax:716-844-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty