Basic Information
| Provider Information | |||||||||
| NPI: | 1538119391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN 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: | 3770 GLENKERRY CT | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490240700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693292887 | ||||||||
| FaxNumber: | 2693292805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | KUIPER | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2693292887 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 050D111320 | 01 | MI | BCBSM | OTHER |