| Organization Name: | GREAT LAKES MEDICAL PC |
| NPI Number: | 1679845671 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RICHARD W MACAULEY (AGENT) |
| Mailing Address: | 1277 E Cedar Avenue Suite A Gladwin |
| State: | MI US |
| Postal Code: | 486247004 |
| Phone Number: | 9894261100 |
| Fax Number: | 9894261400 |
| NPI Enumeration Date: | 02/07/2012 |
| NPI Last Update Date: | 08/27/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 4301042308 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |