1578692307 NPI number — STAT PAIN MANAGEMENT & REHABILITATION SPECIALTIES, LTD.

Table of content: (NPI 1578692307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578692307 NPI number — STAT PAIN MANAGEMENT & REHABILITATION SPECIALTIES, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAT PAIN MANAGEMENT & REHABILITATION SPECIALTIES, LTD.
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:
1578692307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2883 HAWKS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48108-1318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-434-6246
Provider Business Mailing Address Fax Number:
734-434-2307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2883 HAWKS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48108-1318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-434-6246
Provider Business Practice Location Address Fax Number:
734-434-2307
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROZELLE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
734-434-6246

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0007231172 . This is a "AETNA PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 540H104110 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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