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General NPI Number Information
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NPI Number | 1417017476
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Entity Type | Organization
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Legal Business Name | GREAT LAKES PEDIATRIC NEUROLOGY
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1331 MONROE ST
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City | DEARBORN
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State | MI
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Zip | 48124-2888
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Country | US
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Telephone | 248-851-1700
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Fax | 248-851-3830
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Provider Business Mailing Address
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Address Line | 1331 MONROE ST
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City | DEARBORN
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State | MI
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Zip | 48124-2888
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Country | US
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Telephone | 248-851-1700
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Fax | 248-851-3830
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Authorized Official
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Title or Position | PRESIDENT
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Name | YASSER AWAAD
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Credential | MD
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Telephone | 248-851-1700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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