1912724865 NPI number — SUPERIOR INTERVENTIONAL PAIN PLLC

Table of content: NICOLE ANNE WYSOCKI M.D. (NPI 1912342734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912724865 NPI number — SUPERIOR INTERVENTIONAL PAIN PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR INTERVENTIONAL PAIN 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:
1912724865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1190 E 12 MILE RD STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48071-2648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-629-6242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1190 E 12 MILE RD STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-2648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-629-6242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2024

Additional Information

Authorized Official

Authorized Official Last Name:
SHUKR
Authorized Official First Name:
MUSTAFA
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
313-415-2233

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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