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General NPI Number Information
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NPI Number | 1245587633
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Entity Type | Organization
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Legal Business Name | GREAT LAKES MEDICAL SPECIALISTS PLLC
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Dates
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Enumeration Date | 08/06/2012
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Last Update Date | 02/04/2016
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Provider Practice Location Address
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Address Line | 20870 MACK AVENUE
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City | GROSSE POINTE
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State | MI
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Zip | 48236
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Country | US
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Telephone | 517-980-2826
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Fax |
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Provider Business Mailing Address
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Address Line | 20870 MACK AVENUE
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City | GROSSE POINTE
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State | MI
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Zip | 48236
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | THERESA ONEY
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Credential | MD
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Telephone | 517-980-2826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State | MI
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