Provider Demographics
NPI:1316245343
Name:GREAT LAKES PROSTHETICS AND BUSCH DANIEL J MEMBER
Entity type:Organization
Organization Name:GREAT LAKES PROSTHETICS AND BUSCH DANIEL J MEMBER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FAIRMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:734-528-5200
Mailing Address - Street 1:5315 ELLIOTT DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8634
Mailing Address - Country:US
Mailing Address - Phone:734-528-5200
Mailing Address - Fax:734-528-5260
Practice Address - Street 1:5315 ELLIOTT DR
Practice Address - Street 2:SUITE 104
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8634
Practice Address - Country:US
Practice Address - Phone:734-528-5200
Practice Address - Fax:734-528-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4701260001Medicare PIN