Provider Demographics
NPI:1063682730
Name:GREAT LAKES PHYSICIANS OF REDFORD,P.L.L.C.
Entity type:Organization
Organization Name:GREAT LAKES PHYSICIANS OF REDFORD,P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUSTAK
Authorized Official - Middle Name:Y
Authorized Official - Last Name:VAID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-996-8777
Mailing Address - Street 1:23300 PROVIDENCE DR
Mailing Address - Street 2:SUITE # 104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3652
Mailing Address - Country:US
Mailing Address - Phone:248-996-8777
Mailing Address - Fax:248-996-8778
Practice Address - Street 1:25321 5 MILE RD
Practice Address - Street 2:SUITE # 1
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-3700
Practice Address - Country:US
Practice Address - Phone:313-538-1800
Practice Address - Fax:313-538-9082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-09
Last Update Date:2008-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1630863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH56937Medicare UPIN