Provider Demographics
NPI:1689794596
Name:GREAT LAKES EYE ASSOCIATES, PLC
Entity type:Organization
Organization Name:GREAT LAKES EYE ASSOCIATES, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:J
Authorized Official - Last Name:TATGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-667-6408
Mailing Address - Street 1:944 BALDWIN RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3089
Mailing Address - Country:US
Mailing Address - Phone:810-667-6408
Mailing Address - Fax:810-667-6492
Practice Address - Street 1:944 BALDWIN RD
Practice Address - Street 2:SUITE H
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3089
Practice Address - Country:US
Practice Address - Phone:810-667-6408
Practice Address - Fax:810-667-6492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAT014727207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1852510715OtherBCBS
MIP32946FOtherBCN
MI4691258Medicaid
MIY0677Medicare UPIN
MI4691258Medicaid