Basic Information
| Provider Information | |||||||||
| NPI: | 1295826089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES BAY HEALTH CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | GALONSKA | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9897596464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 500G310570 | 01 | MI | BLUECROSS | OTHER |