NPIMap

Organization Active NPI

Great Lakes Surgical Assistants, PLLC

  • Surgical Physician Assistant
  • Troy, MI
National Provider Identifier
1558653303
Registry record updated Jul 21, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgical Physician AssistantTaxonomy code 363AS0400X
License
D5298K Issued in MI
Legal business name
GREAT LAKES SURGICAL ASSISTANTS, PLLC
Practice address
4550 Investment Dr Ste 100
Troy, MI 48098-6334
Phone
(248) 265-4600
NPI assigned
May 12, 2011
Last updated
Jul 21, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2011

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

Authorized official

Name
Brandon E Mackenzie, PA-CNPI 1659349348
Title
Owner, PA-C
Phone
(586) 246-5125

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
Surgical Physician Assistant 363AS0400X D5298K MI Primary

Addresses

Primary practice location

4550 Investment Dr Ste 100
Troy, MI 48098-6334

Mailing address

47120 Land St
Chesterfield, MI 48047-5142
Phone (586) 246-5125

Other identifiers 1

IdentifierTypeStateIssuer
0N33470042OtherMIMEDICARE ID-TYPE UNSPECIFIED

National Provider Directory

National Provider Directory

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": "1305158400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1311206400000",
    "number": "1558653303",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "47120 LAND ST",
            "city": "CHESTERFIELD",
            "state": "MI",
            "postal_code": "480475142",
            "telephone_number": "586-246-5125"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4550 INVESTMENT DR STE 100",
            "city": "TROY",
            "state": "MI",
            "postal_code": "480986334",
            "telephone_number": "248-265-4600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES SURGICAL ASSISTANTS, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-12",
        "last_updated": "2011-07-21",
        "status": "A",
        "authorized_official_last_name": "MACKENZIE",
        "authorized_official_first_name": "BRANDON",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "OWNER, PA-C",
        "authorized_official_telephone_number": "586-246-5125",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "MI",
            "license": "D5298K",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE ID-TYPE UNSPECIFIED",
            "identifier": "0N33470042",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Troy, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.