Provider Demographics
NPI:1366590929
Name:GREAT LAKES NEUROSURGICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:GREAT LAKES NEUROSURGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-242-7042
Mailing Address - Street 1:3350 EAGLE PARK DR NE STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-4570
Mailing Address - Country:US
Mailing Address - Phone:616-454-3465
Mailing Address - Fax:
Practice Address - Street 1:3350 EAGLE PARK DR NE STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4570
Practice Address - Country:US
Practice Address - Phone:616-454-3465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILH029420207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245311059OtherNPI
MI1326144049OtherNPI
MI1497836282OtherNPI
MI1659452472OtherNPI
MI1225119027OtherNPI
MI1770664583OtherNPI
MI1770664583OtherNPI