Provider Demographics
NPI:1295171650
Name:GREAT LAKES MEDICAL, P.C.
Entity type:Organization
Organization Name:GREAT LAKES MEDICAL, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MACAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:517-449-2452
Mailing Address - Street 1:5511 W US HIGHWAY 10
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2455
Mailing Address - Country:US
Mailing Address - Phone:231-843-1553
Mailing Address - Fax:
Practice Address - Street 1:5511 W US HIGHWAY 10
Practice Address - Street 2:SUITE A
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2455
Practice Address - Country:US
Practice Address - Phone:231-843-1553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI04411G261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI04411GOtherMI STATE
MI04411GOtherMI STATE