Provider Demographics
NPI:1033758305
Name:GREAT LAKES REGENERATIVE MEDICINE, PLLC
Entity Type:Organization
Organization Name:GREAT LAKES REGENERATIVE MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BASAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-829-0385
Mailing Address - Street 1:148 GOLF CREST DR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5968
Mailing Address - Country:US
Mailing Address - Phone:248-829-0239
Mailing Address - Fax:678-574-5605
Practice Address - Street 1:2251 N SQUIRREL RD STE 206
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-4602
Practice Address - Country:US
Practice Address - Phone:248-829-0385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-03
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center