Provider Demographics
NPI:1720095417
Name:GREAT LAKES DIALYSIS, L.L.C.
Entity type:Organization
Organization Name:GREAT LAKES DIALYSIS, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL / CMO
Authorized Official - Prefix:
Authorized Official - First Name:MORUFU
Authorized Official - Middle Name:OLATUNJI
Authorized Official - Last Name:ALAUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-741-6830
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-6428
Mailing Address - Country:US
Mailing Address - Phone:815-714-7170
Mailing Address - Fax:630-672-4980
Practice Address - Street 1:14614 KERCHEVAL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2814
Practice Address - Country:US
Practice Address - Phone:313-308-4200
Practice Address - Fax:313-332-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072901261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D1011980OtherCLIA#