Provider Demographics
NPI:1780691808
Name:GREAT LAKES SPINE SPORTS & PAIN, PLLC
Entity type:Organization
Organization Name:GREAT LAKES SPINE SPORTS & PAIN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BACHU
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-772-3800
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-0087
Mailing Address - Country:US
Mailing Address - Phone:231-775-6076
Mailing Address - Fax:231-775-0027
Practice Address - Street 1:4676 E BROOMFIELD RD STE A
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9192
Practice Address - Country:US
Practice Address - Phone:989-772-3800
Practice Address - Fax:840-626-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N55780Medicare PIN