Basic Information
| Provider Information | |||||||||
| NPI: | 1144350521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES GASTROENTEROLOGY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KEITH FRIEDENBERG MD LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 EXETER RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017374665 | ||||||||
| FaxNumber: | 9013281355 | ||||||||
| Practice Location | |||||||||
| Address1: | 8877 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402051225 | ||||||||
| FaxNumber: | 4402051275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | FRIEDENBERG | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4402051225 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 174400000X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.