Provider Demographics
NPI:1952512766
Name:GREAT LAKES BRAIN AND SPINE INSTITUTE PC
Entity Type:Organization
Organization Name:GREAT LAKES BRAIN AND SPINE INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARISH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-782-0500
Mailing Address - Street 1:900 E MICHIGAN AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2457
Mailing Address - Country:US
Mailing Address - Phone:517-782-0500
Mailing Address - Fax:517-782-1713
Practice Address - Street 1:900 E MICHIGAN AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2457
Practice Address - Country:US
Practice Address - Phone:517-782-0500
Practice Address - Fax:517-782-1713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty