Provider Demographics
NPI:1487683504
Name:GREAT LAKES CARDIOLOGY, P.C.
Entity type:Organization
Organization Name:GREAT LAKES CARDIOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEPFRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-5758
Mailing Address - Street 1:1221 6TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2359
Mailing Address - Country:US
Mailing Address - Phone:231-935-5750
Mailing Address - Fax:231-935-5759
Practice Address - Street 1:1221 6TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2359
Practice Address - Country:US
Practice Address - Phone:231-935-5750
Practice Address - Fax:231-935-5759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055166207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060B86046OtherBLUE SHIELD MI GROUP PROV
MI060B86046OtherBLUE SHIELD MI GROUP PROV