Organization
GREAT LAKES SURGICAL ASSISTANTS, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRANDON E MACKENZIE PA-C (OWNER, PA-C)
(586) 246-5125
Entity
Organization
Contact information
Practice address
4550 INVESTMENT DR STE 100, TROY, MI 48098-6334
(248) 265-4600
Mailing address
47120 LAND ST, CHESTERFIELD, MI 48047-5142
(586) 246-5125
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
D5298K
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0N33470042
MEDICARE ID-TYPE UNSPECIFIED
MI
Enumeration date
05/12/2011
Last updated
07/21/2011
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