| Great Lakes Ttc,llc | |
|
2206 Mitchell Park Dr Ste 10 Petoskey MI 49770-8674 | |
| (231) 487-2415 | |
| Not Available |
| Full Name | Great Lakes Ttc,llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 2206 Mitchell Park Dr Ste 10, Petoskey, Michigan |
| Authorized Official Name and Position | Derek Everett Johnson (OWNER) |
| Authorized Official Contact | 2314872415 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Great Lakes Ttc,llc 6935 Zenith Heights Rd Boyne City MI 49712-9356 Ph: (231) 675-5032 | Great Lakes Ttc,llc 2206 Mitchell Park Dr Ste 10 Petoskey MI 49770-8674 Ph: (231) 487-2415 |
| NPI Number | 1659610608 |
|---|---|
| Provider Enumeration Date | 02/12/2013 |
| Last Update Date | 02/12/2013 |
| Medicare PECOS PAC ID | 5890931679 |
|---|---|
| Medicare Enrollment ID | O20130424000201 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659610608 | NPI | - | NPPES |
| 1700139904 | Other | MI | INDIVIDUAL NPI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0850X | Clinic/center - Adult Mental Health | 6801089396 (Michigan) | Primary |
| Provider Name | Ahmad W Zubairi |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1801852694 PECOS PAC ID: 2769464718 Enrollment ID: I20060502000429 |
| Provider Name | Manzar Y Rajput |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1851358527 PECOS PAC ID: 9335277987 Enrollment ID: I20100503000513 |
| Provider Name | Derek E Johnson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1700139904 PECOS PAC ID: 1850537648 Enrollment ID: I20130424000278 |
| Provider Name | Kevin N Batterbee |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1427112572 PECOS PAC ID: 9032268016 Enrollment ID: I20140131001843 |
| Provider Name | Anthony D Diloreto |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1437495298 PECOS PAC ID: 7810118312 Enrollment ID: I20141027001887 |
| Provider Name | Brian L Phillips |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1477955508 PECOS PAC ID: 6901128479 Enrollment ID: I20141211001993 |
| Provider Name | Geraldine A Dorris |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1043269632 PECOS PAC ID: 5496656456 Enrollment ID: I20160805000983 |
| Provider Name | Ikenna Obasi |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1750649455 PECOS PAC ID: 9739337668 Enrollment ID: I20160909001605 |
| Provider Name | Natalie L Ducastel |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1588150460 PECOS PAC ID: 7618226531 Enrollment ID: I20180824002285 |
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