Provider Demographics
NPI:1780056630
Name:GREAT LAKES BRAIN AND SPINE SURGERY, PLLC
Entity type:Organization
Organization Name:GREAT LAKES BRAIN AND SPINE SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVEKANAND
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAVALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-820-6311
Mailing Address - Street 1:3380 BEECHER ROAD
Mailing Address - Street 2:STE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4737
Mailing Address - Country:US
Mailing Address - Phone:810-820-6311
Mailing Address - Fax:
Practice Address - Street 1:3380 BEECHER ROAD
Practice Address - Street 2:STE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4853
Practice Address - Country:US
Practice Address - Phone:810-720-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty