Provider Demographics
NPI:1548663610
Name:GREAT LAKES ACCIDENT SERVICE LTD.
Entity type:Organization
Organization Name:GREAT LAKES ACCIDENT SERVICE LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MYLES
Authorized Official - Middle Name:ANTHONY-ISAAC
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-452-6788
Mailing Address - Street 1:22200 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-7136
Mailing Address - Country:US
Mailing Address - Phone:877-304-1040
Mailing Address - Fax:
Practice Address - Street 1:615 GRISWOLD ST STE 1626
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-3901
Practice Address - Country:US
Practice Address - Phone:877-304-1040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI05674V343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)