Provider Demographics
NPI:1306366810
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:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MESSINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-242-7080
Mailing Address - Street 1:414 PLYMOUTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6038
Mailing Address - Country:US
Mailing Address - Phone:616-454-3465
Mailing Address - Fax:616-454-9004
Practice Address - Street 1:414 PLYMOUTH AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6038
Practice Address - Country:US
Practice Address - Phone:616-454-3465
Practice Address - Fax:616-454-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D11057OtherBLUE CROSS AND BLUE SHIELD OF MICHIGAN
MI1366590929Medicaid