NPIMap

Organization Active NPI

Great Lakes Medical Group PC

  • Internal Medicine Physician
  • Eastpointe, MI
National Provider Identifier
1053787853
Registry record updated Aug 15, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
5315012655 Issued in MI
Legal business name
GREAT LAKES MEDICAL GROUP PC
Practice address
19070 E 10 Mile Rd
Eastpointe, MI 48021-1449
Phone
(313) 418-9952
NPI assigned
Aug 15, 2015
Last updated
Aug 15, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 15, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mohamad Rahbar, M.D.NPI 1679567762
Title
President
Phone
(313) 418-9952

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X 5315012655 MI Primary

Addresses

Primary practice location

19070 E 10 Mile Rd
Eastpointe, MI 48021-1449

Mailing address

19070 E 10 Mile Rd
Eastpointe, MI 48021-1449
Phone (313) 418-9952

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20151002001904 MI Part B Supplier - Clinic/Group Practice 1557679073 Receives reassigned benefits from 12 practitioners
Practice locations: Kimball Township, MI; Memphis, MI; Mount Clemens, MI; Richmond, MI; Detroit, MI; Roseville, MI; Sterling Heights, MI; Warren, MI…

National Provider Directory

National Provider Directory

Locations

34845 Weber Rd
Richmond, MI 48062
Phone (810) 392-3218

72188 Russ Rd
Richmond, MI 48062
Phone (586) 727-7650

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1439596800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1439596800000",
    "number": "1053787853",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19070 E 10 MILE RD",
            "city": "EASTPOINTE",
            "state": "MI",
            "postal_code": "480211449",
            "telephone_number": "313-418-9952"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19070 E 10 MILE RD",
            "city": "EASTPOINTE",
            "state": "MI",
            "postal_code": "480211449",
            "telephone_number": "313-418-9952"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES MEDICAL GROUP PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-08-15",
        "last_updated": "2015-08-15",
        "status": "A",
        "authorized_official_last_name": "RAHBAR",
        "authorized_official_first_name": "MOHAMAD",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "313-418-9952",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "MI",
            "license": "5315012655",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Eastpointe, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.