MEDICARE: GREAT LAKES NEUROMONITORING, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	204R00000X	Electrodiagnostic Medicine Physician
2	2084N0400X	Neurology Physician
3	246ZE0600X	Electroneurodiagnostic Specialist/Technologist
4	2084N0600X	Clinical Neurophysiology Physician

General Provider Information

NPI Number	:	1457866873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES NEUROMONITORING, PLLC

Provider Business Mailing Address
First Line	:	5119 HIGHLAND RD
Second Line	:	(M-59) #389
City	:	WATERFORD
State	:	MI
Zip	:	48327-1915
Country	:	US
Telephone Number	:	248-309-6631
Fax Number	:

Provider Business Practice Location Address
First Line	:	5119 HIGHLAND RD
Second Line	:	(M-59) #389
City	:	WATERFORD
State	:	MI
Zip	:	48327-1915
Country	:	US
Telephone Number	:	248-309-6631
Fax Number	:

Authorized Official
Title or Position	:	MDMS NPI COMPLIANCE OFFICER
Name	:	LIZETTE MORIN
Credential	:
Telephone Number	:	210-598-2801

Provider Enumeration Date	:	12/07/2017
Last Update Date	:	12/07/2017

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