1326091513 NPI number — PAIN TREATMENT CENTERS OF MICHIGAN LLC

Table of content: (NPI 1326091513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326091513 NPI number — PAIN TREATMENT CENTERS OF MICHIGAN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN TREATMENT CENTERS OF MICHIGAN 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:
MATRIX SURGERY CENTER
Provider Other Organization Name Type Code:
3
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:
1326091513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4450 FASHION SQUARE BLVD
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48603-1251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-790-7950
Provider Business Mailing Address Fax Number:
989-790-1770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4450 FASHION SQUARE BLVD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48603-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-790-7950
Provider Business Practice Location Address Fax Number:
989-790-1770
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORAN
Authorized Official First Name:
JENETHA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OFFICER / AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
972-763-3893

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  1010000059 , 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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