Provider Demographics
NPI:1154380822
Name:GREAT LAKES REHAB, LLC
Entity type:Organization
Organization Name:GREAT LAKES REHAB, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:T
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-533-0919
Mailing Address - Street 1:6674 TIPPECANOE RD
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9149
Mailing Address - Country:US
Mailing Address - Phone:330-533-0919
Mailing Address - Fax:330-533-1732
Practice Address - Street 1:6674 TIPPECANOE RD
Practice Address - Street 2:SUITE # 1
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9149
Practice Address - Country:US
Practice Address - Phone:330-533-0919
Practice Address - Fax:330-533-1732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 071295208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2118578Medicaid
OH9344801Medicare PIN
OHG92085Medicare UPIN