Basic Information
| Provider Information | |||||||||
| NPI: | 1467418574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN PAIN CONSULTANTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 GLENWOOD HILLS PKWY SE STE 2 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169402662 | ||||||||
| FaxNumber: | 6169401965 | ||||||||
| Practice Location | |||||||||
| Address1: | 2060 EAST PARIS AVE SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162851377 | ||||||||
| FaxNumber: | 6162851006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOSTINE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6162851377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700D160000 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |