NPIMap

Organization Active NPI

Great Lakes Bay Health Centers

  • Federally Qualified Health Center (FQHC)
  • Bridgeport, MI
National Provider Identifier
1073169835
Registry record updated Aug 26, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
GREAT LAKES BAY HEALTH CENTERS
Practice address
4691 Bearcat Blvd
Bridgeport, MI 48722-9581
Phone
(989) 777-0440
NPI assigned
Aug 16, 2019
Last updated
Aug 26, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 26, 2019

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

Authorized official

Name
Dawn Christian
Title
Provider Enrollment
Phone
(989) 759-6464

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

4691 Bearcat Blvd
Bridgeport, MI 48722-9581

Mailing address

501 Lapeer Ave
Saginaw, MI 48607-1203
Phone (989) 759-6464

Other names 1

  • Great Lakes Bay Health Centers Bridgeport Spaulding High School Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191105001236 MI Part A Provider - Federally Qualified Health Center (FQHC) 2466369046 Practice locations: Bridgeport, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073169835. Details of each certification follow.

Federally qualified health center certification: CCN 231152

Legal name
GREAT LAKES BAY HEALTH CENTERS
Doing business as
GREAT LAKES BAY HEALTH CENTERS BRIDGEPORT SPAULDING HIGH SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 2, 2019
Last certification
Nov 2, 2019
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
4691 Bearcat Blvd
FL 1
Bridgeport, MI 48722-9581

National Provider Directory

National Provider Directory
Tax ID family
Great Lakes Bay Health Centers67 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 15

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 15

Locations

4691 Bearcat Blvd
Bridgeport, MI 48722
Phone (989) 777-0440

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Albert Martenis Individual Corporate DirectorBoard Member Oct 1, 2019
Deborah Mack Individual Corporate DirectorBoard Member Oct 1, 2019
Brenda M Coughlin Individual W-2 Managing EmployeeCeo Oct 1, 2019
Timothy Zlomak Individual Corporate DirectorBoard Member Oct 1, 2019
Lisa Wilson Individual Corporate DirectorBoard Member Jan 19, 2026
Monica Reyes Individual Corporate DirectorBoard Member Oct 1, 2019
Josie King Individual Corporate DirectorBoard Member Jan 19, 2026
Tarshia Lewis Individual Corporate DirectorBoard Member Oct 1, 2019
Jacob Cristoforo Individual Corporate DirectorBoard Member Jan 19, 2026
Dawn Christian Individual Corporate Officer Oct 1, 2019
Saleem a Mannan Individual Corporate DirectorBoard Member Jan 19, 2026
Michelle Stolsmark Individual Corporate DirectorBoard Member Jan 19, 2026
Lisa Galonska Individual Corporate Officer Oct 1, 2019
John Rezayi Individual Corporate DirectorBoard Member Jan 19, 2026
John a Martin Individual Corporate DirectorBoard Member Jan 19, 2026
Sam Pruitt Individual Corporate DirectorBoard Member Oct 1, 2019
Dwayne Parker Individual Corporate DirectorBoard Member Oct 1, 2019

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

NPI Registry JSON

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

{
    "created_epoch": "1565913600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1566777600000",
    "number": "1073169835",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "501 LAPEER AVE",
            "city": "SAGINAW",
            "state": "MI",
            "postal_code": "486071203",
            "telephone_number": "989-759-6464",
            "fax_number": "989-399-8233"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4691 BEARCAT BLVD",
            "city": "BRIDGEPORT",
            "state": "MI",
            "postal_code": "487229581",
            "telephone_number": "989-777-0440"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES BAY HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-16",
        "last_updated": "2019-08-26",
        "status": "A",
        "authorized_official_last_name": "CHRISTIAN",
        "authorized_official_first_name": "DAWN",
        "authorized_official_title_or_position": "PROVIDER ENROLLMENT",
        "authorized_official_telephone_number": "989-759-6464"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Great Lakes Bay Health Centers Bridgeport Spaulding High School",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Great Lakes Bay Health Centers Bridgeport Spaulding High School",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Bridgeport, MI

Sources for this page

Verify at the official NPI Registry.