NPIMap

Organization Active NPI

Great Lakes Bay Health Centers

  • Federally Qualified Health Center (FQHC)
  • Bridgeport, MI
National Provider Identifier
1215055306
Registry record updated Sep 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
6297 Dixie Highway
Bridgeport, MI 48722-9635
Phone
(989) 759-6460
Fax
(989) 759-6465
NPI assigned
Mar 27, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 19, 2016

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

Authorized official

Name
Lisa Galonska
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

6297 Dixie Highway
Bridgeport, MI 48722-9635

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
0G36111OtherMI0G36111 MEDICARE BILL PAY TO

Other names 1

  • Great Lakes Bay Health Centers Bridgeport Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20061212000671 MI Part A Provider - Federally Qualified Health Center (FQHC) 2466369046 1 other NPI on this enrollment
Practice locations: Bridgeport, MI

Federally qualified health center certification: CCN 231882

Legal name
GREAT LAKES BAY HEALTH CENTERS
Doing business as
GREAT LAKES BAY HEALTH CENTERS BRIDGEPORT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 1, 2001
Last certification
Sep 1, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 1, 1968 in MI
Enrollment address
6297 Dixie Hwy
Bridgeport, MI 48722-9635

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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 24

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

View all 24

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Craig Tatum Individual Corporate Director Feb 16, 2023
Suzanne Prich Individual Corporate Director Jan 4, 2017
Albert Martenis Individual Corporate Director Jan 4, 2017
Deborah Mack Individual Corporate DirectorTreasurer Jan 4, 2017
Tracey S Dore Individual Corporate Director Feb 16, 2023
Brenda M Coughlin Individual W-2 Managing EmployeeCeo Jan 4, 2017
Timothy Zlomak Individual Corporate DirectorChairman Jan 4, 2017
Jesus Hernandez Individual Corporate Director Jan 4, 2017
Monica Reyes Individual Corporate Director Feb 16, 2023
Josie King Individual Corporate Director Feb 16, 2023
Dawn Christian Individual Corporate OfficerProvider Enrollment Coordinator Jan 4, 2017
Saleem a Mannan Individual Corporate Director Feb 16, 2023
Michelle Stolsmark Individual Corporate Director Feb 16, 2023
Lisa Galonska Individual Corporate OfficerVice President Dec 1, 2011
Sam Pruitt Individual Corporate DirectorSecretary Jan 4, 2017
Dwayne Parker Individual Corporate Director Feb 16, 2023

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": "1174953600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1474243200000",
    "number": "1215055306",
    "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": "6297 DIXIE HIGHWAY",
            "city": "BRIDGEPORT",
            "state": "MI",
            "postal_code": "487229635",
            "telephone_number": "989-759-6460",
            "fax_number": "989-759-6465"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES BAY HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-27",
        "last_updated": "2016-09-19",
        "status": "A",
        "authorized_official_last_name": "GALONSKA",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "989-759-6464"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MI",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "0G36111  MEDICARE BILL PAY TO",
            "identifier": "0G36111",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Great Lakes Bay Health Centers Bridgeport",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Bridgeport, MI

Sources for this page

Verify at the official NPI Registry.