NPIMap

Organization Active NPI

Great Lakes Neurosurgical Associates, PC

  • Neurological Surgery Physician
  • Grand Rapids, MI
National Provider Identifier
1366590929
Registry record updated Oct 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurological Surgery PhysicianTaxonomy code 207T00000X
License
LH029420 Issued in MI
Legal business name
GREAT LAKES NEUROSURGICAL ASSOCIATES, PC
Practice address
3350 Eagle Park Dr NE Ste 102
Grand Rapids, MI 49525-4570
Phone
(616) 454-3465
NPI assigned
Jan 8, 2007
Last updated
Oct 24, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 24, 2023

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

Authorized official

Name
Lisa Santos
Title
Executive Director
Phone
(616) 242-7042

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Neurological Surgery Physician 207T00000X LH029420 MI Primary

Addresses

Primary practice location

3350 Eagle Park Dr NE Ste 102
Grand Rapids, MI 49525-4570

Mailing address

3350 Eagle Park Dr NE Ste 102
Grand Rapids, MI 49525-4570
Phone (616) 454-3465

Other identifiers 6

IdentifierTypeStateIssuer
1497836282OtherMINPI
1770664583OtherMINPI
1326144049OtherMINPI
1659452472OtherMINPI
1225119027OtherMINPI
1245311059OtherMINPI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20031209000125 MI Part B Supplier - Clinic/Group Practice 5890691182 Receives reassigned benefits from 12 practitioners
Practice locations: Grand Rapids, MI
O20050209000481 MI Part B Supplier - Clinic/Group Practice 5890691182 Receives reassigned benefits from 7 practitioners
Practice locations: Grand Rapids, MI
O20110811000839 MI DME Supplier - Physician - Neurosurgery 5890691182 Practice locations: Grand Rapids, MI

National Provider Directory

National Provider Directory

Locations

3350 Eagle Park Dr NE
Ste 102
Grand Rapids, MI 49525
Phone (616) 242-7042

3299 N Wellness Dr
Bldg C
Holland, MI 49424
Phone (616) 738-4420

3299 N Wellness Dr
Ste C240
Holland, MI 49424

Practitioners & affiliated clinicians

Practitioners 23

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 23

NPI Registry JSON

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

{
    "created_epoch": "1168214400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698105600000",
    "number": "1366590929",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3350 EAGLE PARK DR NE STE 102",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495254570",
            "telephone_number": "616-454-3465"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3350 EAGLE PARK DR NE STE 102",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495254570",
            "telephone_number": "616-454-3465"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES NEUROSURGICAL ASSOCIATES, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-08",
        "last_updated": "2023-10-24",
        "certification_date": "2023-10-24",
        "status": "A",
        "authorized_official_last_name": "SANTOS",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "616-242-7042"
    },
    "taxonomies": [
        {
            "code": "207T00000X",
            "taxonomy_group": "",
            "desc": "Neurological Surgery",
            "state": "MI",
            "license": "LH029420",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1497836282",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1770664583",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1326144049",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1659452472",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1225119027",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1245311059",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2023; 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.