=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720890098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT LAKES SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2025
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 E BELTLINE AVE NE STE 101
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-4598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-786-2040
-----------------------------------------------------
Fax | 302-261-7479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 E BELTLINE AVE NE STE 101
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-4598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-786-2040
-----------------------------------------------------
Fax | 302-261-7479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OF ENTITY
-----------------------------------------------------
Name | AAMIR ABBAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-786-2040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------