1033758305 NPI number — GREAT LAKES REGENERATIVE MEDICINE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033758305 NPI number — GREAT LAKES REGENERATIVE MEDICINE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES REGENERATIVE MEDICINE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033758305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 GOLF CREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ACWORTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30101-5968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-829-0239
Provider Business Mailing Address Fax Number:
678-574-5605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2251 N SQUIRREL RD STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48326-4602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-829-0385
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BASAK
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
248-829-0385

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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