Provider Demographics
NPI:1417017476
Name:GREAT LAKES PEDIATRIC NEUROLOGY
Entity Type:Organization
Organization Name:GREAT LAKES PEDIATRIC NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YASSER
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-851-1700
Mailing Address - Street 1:1331 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2888
Mailing Address - Country:US
Mailing Address - Phone:248-851-1700
Mailing Address - Fax:248-851-3830
Practice Address - Street 1:1331 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2888
Practice Address - Country:US
Practice Address - Phone:248-851-1700
Practice Address - Fax:248-851-3830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty