Provider Demographics
NPI:1679717466
Name:GREATER LAKES AMBULATORY SURGICAL CENTER, LLC
Entity type:Organization
Organization Name:GREATER LAKES AMBULATORY SURGICAL CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:ANITA
Authorized Official - Last Name:BRYNAERT
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, RNFA
Authorized Official - Phone:586-286-0000
Mailing Address - Street 1:16100 19 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1148
Mailing Address - Country:US
Mailing Address - Phone:586-286-0000
Mailing Address - Fax:586-286-0005
Practice Address - Street 1:16100 19 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1148
Practice Address - Country:US
Practice Address - Phone:586-286-0000
Practice Address - Fax:586-286-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI506836261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical