Provider Demographics
NPI:1588600522
Name:GREAT LAKES OTOLARYNGOLOGY PC
Entity type:Organization
Organization Name:GREAT LAKES OTOLARYNGOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-372-7205
Mailing Address - Street 1:2223 W STATE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1938
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:2223 W STATE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1938
Practice Address - Country:US
Practice Address - Phone:716-692-3302
Practice Address - Fax:716-692-4342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02079463Medicaid
NY02079463Medicaid