Provider Demographics
NPI:1427155357
Name:GREAT LAKES CANCER MGMT SPECIALISTS
Entity type:Organization
Organization Name:GREAT LAKES CANCER MGMT SPECIALISTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-884-5524
Mailing Address - Street 1:11051 HALL RD
Mailing Address - Street 2:STE 120
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11051 HALL RD
Practice Address - Street 2:STE 120
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5735
Practice Address - Country:US
Practice Address - Phone:586-991-0700
Practice Address - Fax:586-991-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056352332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4231200Medicaid
2367159OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OH26126009Medicare ID - Type Unspecified