Healthcare Provider Details

I. General information

NPI: 1366590929
Provider Name (Legal Business Name): GREAT LAKES NEUROSURGICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 EAGLE PARK DR NE STE 102
GRAND RAPIDS MI
49525-4570
US

IV. Provider business mailing address

3350 EAGLE PARK DR NE STE 102
GRAND RAPIDS MI
49525-4570
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-3465
  • Fax:
Mailing address:
  • Phone: 616-454-3465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberLH029420
License Number StateMI

VIII. Authorized Official

Name: LISA SANTOS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 616-242-7042