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General NPI Number Information
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NPI Number | 1780691808
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Entity Type | Organization
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Legal Business Name | GREAT LAKES SPINE SPORTS & PAIN, PLLC
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Dates
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Enumeration Date | 08/02/2006
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Last Update Date | 10/03/2007
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Provider Practice Location Address
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Address Line | 4676 E BROOMFIELD RD STE A
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City | MT PLEASANT
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State | MI
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Zip | 48858-9192
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Country | US
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Telephone | 989-772-3800
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Fax | 840-626-4066
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Provider Business Mailing Address
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Address Line | PO BOX 87
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City | CADILLAC
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State | MI
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Zip | 49601-0087
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Country | US
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Telephone | 231-775-6076
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Fax | 231-775-0027
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Authorized Official
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Title or Position | PRESIDENT
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Name | BACHU ABRAHAM
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Credential | M.D.
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Telephone | 989-772-3800
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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 |
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