Provider Demographics
NPI:1336847730
Name:GREAT LAKES SPINE AND MEDICAL PLLC
Entity Type:Organization
Organization Name:GREAT LAKES SPINE AND MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-792-6702
Mailing Address - Street 1:4266 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-4035
Mailing Address - Country:US
Mailing Address - Phone:989-792-6702
Mailing Address - Fax:989-792-1128
Practice Address - Street 1:4266 STATE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-4035
Practice Address - Country:US
Practice Address - Phone:989-792-6702
Practice Address - Fax:989-792-1128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies