Basic Information
Provider Information
NPI: 1912265547
EntityType: 2
ReplacementNPI:  
OrganizationName: GREAT LAKES BAY HEALTH CENTERS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: GREAT LAKES BAY HEALTH CENTERS SHIAWASSEE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 501 LAPEER
Address2:  
City: SAGINAW
State: MI
PostalCode: 486071208
CountryCode: US
TelephoneNumber: 9897596464
FaxNumber: 9893998233
Practice Location
Address1: 200 N CALEDONIA DR
Address2:  
City: OWOSSO
State: MI
PostalCode: 48867
CountryCode: US
TelephoneNumber: 9897294848
FaxNumber: 9897294849
Other Information
ProviderEnumerationDate: 05/02/2012
LastUpdateDate: 08/07/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GALSONSKA
AuthorizedOfficialFirstName: LISA
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: INTERUM PRESIDENT
AuthorizedOfficialTelephone: 9897596448
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261Q00000X  N Ambulatory Health Care FacilitiesClinic/Center 
261QF0400X MIY Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

No ID Information.


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