NPIMap

Organization Active NPI

Great Lakes Healthcare, PLLC

  • Family Medicine Physician
  • Peck, MI
National Provider Identifier
1881855328
Registry record updated Nov 10, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5101008768 Issued in MI
Legal business name
GREAT LAKES HEALTHCARE, PLLC
Practice address
251 E Peck Rd
Peck, MI 48466-9589
Phone
(810) 378-4900
Fax
(810) 378-4905
NPI assigned
Jun 18, 2008
Last updated
Nov 10, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 10, 2009

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

Authorized official

Name
Dr. Kenneth Eugene Dambacher, D.O.NPI 1194701946
Title
Owner
Phone
(810) 378-4900

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 5101008768 MI Primary

Addresses

Primary practice location

251 E Peck Rd
Peck, MI 48466-9589

Mailing address

PO Box 129
Yale, MI 48097-0129
Phone (810) 378-4900

Other identifiers 3

IdentifierTypeStateIssuer
5670042OtherMIBLUE CROSS BLUE SHIELD OF MICHIGAN
08-0G61059-0OtherMIBLUE CROSS BLUE SHIELD OF MICHIGAN
114469926MedicaidMI

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

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": "1213747200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1257811200000",
    "number": "1881855328",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 129",
            "city": "YALE",
            "state": "MI",
            "postal_code": "480970129",
            "telephone_number": "810-378-4900",
            "fax_number": "810-378-4905"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "251 E PECK RD",
            "city": "PECK",
            "state": "MI",
            "postal_code": "484669589",
            "telephone_number": "810-378-4900",
            "fax_number": "810-378-4905"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES HEALTHCARE, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-18",
        "last_updated": "2009-11-10",
        "status": "A",
        "authorized_official_last_name": "DAMBACHER",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "EUGENE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "810-378-4900",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "5101008768",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD OF MICHIGAN",
            "identifier": "5670042",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD OF MICHIGAN",
            "identifier": "08-0G61059-0",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "114469926",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Peck, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 10, 2009; 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.