Provider Demographics
NPI:1104158690
Name:UPPER GREAT LAKES FAMILY HEALTH CENTER
Entity type:Organization
Organization Name:UPPER GREAT LAKES FAMILY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-483-1325
Mailing Address - Street 1:301 EXPLORER ST
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-2813
Mailing Address - Country:US
Mailing Address - Phone:906-346-9275
Mailing Address - Fax:906-372-3230
Practice Address - Street 1:135 EAST M 35
Practice Address - Street 2:
Practice Address - City:GWINN
Practice Address - State:MI
Practice Address - Zip Code:49841-9159
Practice Address - Country:US
Practice Address - Phone:906-346-9275
Practice Address - Fax:906-372-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231954Medicare Oscar/Certification
MIMI2894Medicare PIN