1720039977 NPI number — GREAT LAKES ANESTHESIA, P.C.

Table of content: (NPI 1720039977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720039977 NPI number — GREAT LAKES ANESTHESIA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES ANESTHESIA, P.C.
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:
1720039977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46515-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-522-9922
Provider Business Mailing Address Fax Number:
574-522-9926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 E BEARDSLEY AVE STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-3371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-522-9922
Provider Business Practice Location Address Fax Number:
574-522-9926
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLAXTON
Authorized Official First Name:
SETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
574-522-9922

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200250870 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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