Basic Information
| Provider Information | |||||||||
| NPI: | 1710181128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREAT LAKES BAY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREAT LAKES BAY HEALTH CENTERS IMLAY CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 6800 NEWARK RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | IMLAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484449656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107243201 | ||||||||
| FaxNumber: | 8107244605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | GALONSKA | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9897596464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0G36111 | 01 | MI | 0G36111 MEDICARE PAY BILL TO | OTHER |