Provider Demographics
NPI:1598737769
Name:GREAT LAKES FAMILY MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:GREAT LAKES FAMILY MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARUNIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-266-2780
Mailing Address - Street 1:28801 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-2385
Mailing Address - Country:US
Mailing Address - Phone:734-266-2780
Mailing Address - Fax:734-466-9615
Practice Address - Street 1:4420 E DAVISON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-1744
Practice Address - Country:US
Practice Address - Phone:313-369-1500
Practice Address - Fax:313-369-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N63770Medicare ID - Type Unspecified