Provider Demographics
NPI:1992855639
Name:GREAT LAKES ELECTROPHYSIOLOGICAL TESTING SERVICES
Entity Type:Organization
Organization Name:GREAT LAKES ELECTROPHYSIOLOGICAL TESTING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHYAWAN
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:BANSIL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PHD
Authorized Official - Phone:248-489-1771
Mailing Address - Street 1:28959 AUGUSTA
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-4822
Mailing Address - Country:US
Mailing Address - Phone:248-489-1771
Mailing Address - Fax:248-489-1771
Practice Address - Street 1:28959 AUGUSTA
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-4822
Practice Address - Country:US
Practice Address - Phone:248-489-1771
Practice Address - Fax:248-489-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty