1598742801 NPI number — GREAT LAKES PHYSICIANS LLC

Table of content: (NPI 1598742801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598742801 NPI number — GREAT LAKES PHYSICIANS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES PHYSICIANS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598742801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6681 RIDGE ROAD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PARMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44129-5713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-398-0863
Provider Business Mailing Address Fax Number:
216-351-3619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6681 RIDGE ROAD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44129-5713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-398-0863
Provider Business Practice Location Address Fax Number:
216-351-3619
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SAGHAFI
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
216-702-0360

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2518798 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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