Basic Information
| Provider Information | |||||||||
| NPI: | 1588600522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES OTOLARYNGOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2223 W STATE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 2223 W STATE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | LAI | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7163727205 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 02079463 | 05 | NY | MEDICAID |