Great Lakes Pain Management MD, PC

Primary specialty

Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X

Legal business name

GREAT LAKES PAIN MANAGEMENT MD, PC

Practice address

1404 Eureka Ave
Wyandotte, MI 48192

Phone

(734) 282-4200

Fax

(734) 282-4210

NPI assigned

Dec 4, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mohamed L Othman, M.D.

Title

President

Phone

(734) 282-4200

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Elizabeth Anne Christie, NP

  • Family Nurse Practitioner
  • Wyandotte, MI
  • NPI 1891390639

  Single Specialty

  Medicare reassignment Care Compare group NPD
• Mohamed L Osman, MD

  • Anesthesiology Physician
  • Detroit, MI
  • NPI 1306954227
  Medicare reassignment Care Compare group NPD
• Anita A Parker, PA

  • Physician Assistant
  • Macomb, MI
  • NPI 1700067824
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1356419543",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1404 EUREKA AVE",
            "city": "WYANDOTTE",
            "state": "MI",
            "postal_code": "48192",
            "telephone_number": "734-282-4200",
            "fax_number": "734-282-4210"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1404 EUREKA AVE",
            "city": "WYANDOTTE",
            "state": "MI",
            "postal_code": "48192",
            "telephone_number": "734-282-4200",
            "fax_number": "734-282-4210"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES PAIN MANAGEMENT MD, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-04",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "OTHMAN",
        "authorized_official_first_name": "MOHAMED",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "734-282-4200",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "208VP0014X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Anita Mari Gosselin
• Ari S. Gotlib, MD
• Al DG Mandeoya Grande, OTRL
• Alicia Paulette Gray, DO
• Samuel Allen Gray
• Great Lakes Pharmacy LLC
• Great Lakes Physical Medicine & Rehabilitation PC
• Great Lakes Physical Medicine and Rehabilitation
• Bradley Allen Green, CRNA, MS
• Joshua C. Greenberg, M.D.

• Interventional Pain Medicine Physician in Wyandotte, MI
• Providers in Wyandotte, MI by specialty
• Interventional Pain Medicine Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.