Basic Information
| Provider Information | |||||||||
| NPI: | 1194341834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREAT LAKES BAY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 LAPEER AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 S TRUMBULL ST | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487087692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9899225710 | ||||||||
| FaxNumber: | 9897717051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2020 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTIAN | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 9897596464 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.