NPIMap

Organization Active NPI

Great Lakes Bay Health Centers

  • Federally Qualified Health Center (FQHC)
  • Owosso, MI
National Provider Identifier
1134491202
Registry record updated Dec 19, 2016
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
1555 Industrial Drive
Owosso, MI 48867
Phone
(989) 759-6464
Fax
(989) 399-8233
NPI assigned
Feb 3, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 19, 2016

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

Authorized official

Name
Lisa M Galonska, BS
Title
Vice President
Phone
(989) 759-6464

Specialties & licenses 1

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

Addresses

Primary practice location

1555 Industrial Drive
Owosso, MI 48867

Mailing address

501 Lapeer
Saginaw, MI 48607-1208
Phone (989) 759-6464

Other names 1

  • Great Lakes Bay Health Centers Integrated Care Shiawassee Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120319000822 MI Part A Provider - Federally Qualified Health Center (FQHC) 2466369046 Practice locations: Owosso, MI

Federally qualified health center certification: CCN 231968

Legal name
GREAT LAKES BAY HEALTH CENTERS
Doing business as
GREAT LAKES BAY HEALTH CENTERS INTEGRATED CARE SHIAWASSEE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 1, 2012
Last certification
May 1, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 1, 1968 in MI
Enrollment address
1555 Industrial Dr
Owosso, MI 48867-9775

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2037221Great Lakes Bay Health Centers1555 Industrial Drive, Owosso, MI 48867Certificate of waiverFeb 21, 2028

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 17

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

View all 17

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Michael Durussel Individual Corporate DirectorBoard Member Sep 13, 2016
Suzanne Prich Individual Corporate DirectorBoard Member Sep 13, 2016
Albert Martenis Individual Corporate DirectorBoard Member Sep 13, 2016
Deborah Mack Individual Corporate DirectorBoard Member Sep 13, 2016
Brenda M Coughlin Individual W-2 Managing EmployeePresident Ceo Sep 13, 2016
Timothy Zlomak Individual Corporate DirectorBoard Member Sep 13, 2016
Jesus Hernandez Individual Corporate DirectorBoard Member Sep 13, 2016
Tarshia Lewis Individual Corporate DirectorBoard Member Sep 13, 2016
Dawn Christian Individual Corporate Officer Nov 10, 2016
Lisa Galonska Individual Corporate Officer Sep 13, 2016
Corporate Director Sep 13, 2016
W-2 Managing EmployeeInterim President Feb 3, 2014
Carni Applegate Individual Corporate DirectorBoard Member Sep 13, 2016
Sam Pruitt Individual Corporate DirectorBoard Member Sep 13, 2016

Owners & managing parties with NPI records 1

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": "1328227200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1482105600000",
    "number": "1134491202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "501 LAPEER",
            "city": "SAGINAW",
            "state": "MI",
            "postal_code": "486071208",
            "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": "1555 INDUSTRIAL DRIVE",
            "city": "OWOSSO",
            "state": "MI",
            "postal_code": "48867",
            "telephone_number": "989-759-6464",
            "fax_number": "989-399-8233"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES BAY HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-02-03",
        "last_updated": "2016-12-19",
        "status": "A",
        "authorized_official_last_name": "GALONSKA",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "989-759-6464",
        "authorized_official_credential": "BS"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MI",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Great Lakes Bay Health Centers Integrated Care Shiawassee",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Owosso, MI

Sources for this page

Verify at the official NPI Registry.