Basic Information
| Provider Information | |||||||||
| NPI: | 1255370094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES PAIN CONSULT PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 COMMERCE AVE SW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400660 | ||||||||
| FaxNumber: | 6169401965 | ||||||||
| Practice Location | |||||||||
| Address1: | 4121 SHRESTHA DR | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896866900 | ||||||||
| FaxNumber: | 9896866911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | GROVER | ||||||||
| AuthorizedOfficialFirstName: | THERON | ||||||||
| AuthorizedOfficialMiddleName: | HUGH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9896866911 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 050Z901090 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |