Provider Demographics
NPI:1548668585
Name:GREAT LAKES PHYSICIAN PRACTICE PC
Entity type:Organization
Organization Name:GREAT LAKES PHYSICIAN PRACTICE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:EHALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-647-0943
Mailing Address - Street 1:113 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:14136-1452
Mailing Address - Country:US
Mailing Address - Phone:716-934-3641
Mailing Address - Fax:716-934-7443
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:NY
Practice Address - Zip Code:14136-1452
Practice Address - Country:US
Practice Address - Phone:716-934-3641
Practice Address - Fax:716-934-7443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100168828Medicare PIN