Basic Information
| Provider Information | |||||||||
| NPI: | 1225302821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN CLINIC MANAGEMENT GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 772211 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482772211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004446110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35634 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483104288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869787250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2012 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | PETER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5869787250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.