Provider Demographics
NPI:1255370094
Name:GREAT LAKES PAIN CONSULT PLLC
Entity type:Organization
Organization Name:GREAT LAKES PAIN CONSULT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THERON
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-686-6911
Mailing Address - Street 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4124
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:4121 SHRESTHA DR
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706
Practice Address - Country:US
Practice Address - Phone:989-686-6900
Practice Address - Fax:989-686-6911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI050Z901090OtherBLUE CROSS BLUE SHIELD
MI0N98030Medicare PIN
MI050Z901090OtherBLUE CROSS BLUE SHIELD
MI0N80100Medicare PIN