Provider Demographics
NPI:1629447719
Name:GREAT LAKES INTERVENTIONAL PAIN MANAGEMENT,PLLC
Entity Type:Organization
Organization Name:GREAT LAKES INTERVENTIONAL PAIN MANAGEMENT,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITHA
Authorized Official - Middle Name:RUKKANNAGARI
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-410-5148
Mailing Address - Street 1:1311 S LINDEN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3428
Mailing Address - Country:US
Mailing Address - Phone:810-230-1210
Mailing Address - Fax:810-230-1225
Practice Address - Street 1:1311 S LINDEN RD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3428
Practice Address - Country:US
Practice Address - Phone:810-230-1210
Practice Address - Fax:810-230-1225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010850402081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174515084OtherNPI
MI5353030Medicaid
MI1174515084OtherNPI