1124402607 NPI number — INTERVENTIONAL PAIN SPECIALISTS OF MICHIGAN PLLC

Table of content: (NPI 1124402607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124402607 NPI number — INTERVENTIONAL PAIN SPECIALISTS OF MICHIGAN PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN SPECIALISTS OF MICHIGAN 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:
1124402607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14000 DIX TOLEDO RD
Provider Second Line Business Mailing Address:
PO BOX 1915
Provider Business Mailing Address City Name:
SOUTHGATE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48195-9500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-263-5961
Provider Business Mailing Address Fax Number:
313-263-5963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13460 FORT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195-1138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-263-5961
Provider Business Practice Location Address Fax Number:
313-263-5963
Provider Enumeration Date:
07/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SRIPADA
Authorized Official First Name:
SIVA
Authorized Official Middle Name:
KUMAR
Authorized Official Title or Position:
ADMIN
Authorized Official Telephone Number:
810-275-9152

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  5101016685 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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