Basic Information
| Provider Information | |||||||||
| NPI: | 1063831303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN MANAGEMENT GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33792 | ||||||||
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| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482323781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005144390 | ||||||||
| FaxNumber: | 4408083675 | ||||||||
| Practice Location | |||||||||
| Address1: | 229 W. MAIN CROSS ST | ||||||||
| Address2: | STE 58 | ||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197216358 | ||||||||
| FaxNumber: | 8002610301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | HECKER | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3304386352 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1063831303 | 05 | MI | MEDICAID | 7100363390 | 05 | KY | MEDICAID | 1063831303 | 05 | IL | MEDICAID | 0107443 | 05 | OH | MEDICAID |