1063831303 NPI number — PAIN MANAGEMENT GROUP LLC

Table of content: (NPI 1063831303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063831303 NPI number — PAIN MANAGEMENT GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT GROUP LLC
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:
1063831303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33792
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48232-3781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-514-4390
Provider Business Mailing Address Fax Number:
440-808-3675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 W. MAIN CROSS ST
Provider Second Line Business Practice Location Address:
STE 58
Provider Business Practice Location Address City Name:
FINDLAY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-721-6358
Provider Business Practice Location Address Fax Number:
800-261-0301
Provider Enumeration Date:
04/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HECKER
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
330-438-6352

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1063831303 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100363390 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063831303 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0107443 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com