Provider Demographics
NPI:1487760427
Name:GREAT LAKES CARDIOVASCULAR THORACIC SURGERY, PLC
Entity type:Organization
Organization Name:GREAT LAKES CARDIOVASCULAR THORACIC SURGERY, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-372-8687
Mailing Address - Street 1:7901 S 12TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3831
Mailing Address - Country:US
Mailing Address - Phone:269-372-8687
Mailing Address - Fax:
Practice Address - Street 1:7901 S 12TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3831
Practice Address - Country:US
Practice Address - Phone:269-372-8687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009076208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P35660Medicare PIN