Healthcare Provider Details

I. General information

NPI: 1811096548
Provider Name (Legal Business Name): GREAT LAKES PHYSIATRISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25311 LITTLE MACK AVE SUITE B
ST CLAIR SHORES MI
48081
US

IV. Provider business mailing address

8301 RELIABLE PKWY
CHICAGO IL
60686-0083
US

V. Phone/Fax

Practice location:
  • Phone: 586-498-2400
  • Fax: 586-498-2800
Mailing address:
  • Phone: 586-498-2400
  • Fax: 586-498-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301045967
License Number StateMI

VIII. Authorized Official

Name: DR. FRANK S POLLINA
Title or Position: PRESIDENT
Credential: MD
Phone: 586-498-2400