Provider Demographics
NPI:1366589996
Name:GREAT LAKES GYNECOLOGY & AESTHETICS INC, PC
Entity type:Organization
Organization Name:GREAT LAKES GYNECOLOGY & AESTHETICS INC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:HAMACHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FACOG
Authorized Official - Phone:906-233-9500
Mailing Address - Street 1:126 SOUTH 25TH STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829
Mailing Address - Country:US
Mailing Address - Phone:906-233-9500
Mailing Address - Fax:906-233-9925
Practice Address - Street 1:126 S 25TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1364
Practice Address - Country:US
Practice Address - Phone:906-233-9500
Practice Address - Fax:906-233-9925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207VG0400X207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4662541Medicaid
MIF42051Medicare UPIN
MIP02830001Medicare ID - Type Unspecified