Basic Information
Provider Information | |||||||||
NPI: | 1659798627 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPINE AND JOINT PAIN MANAGEMENT CENTER PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPINE AND JOINT PAIN MANAGEMENT CENTER PC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1221 BOWERS ST UNIT 2653 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | MI | ||||||||
PostalCode: | 480127104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9376733983 | ||||||||
FaxNumber: | 2482813535 | ||||||||
Practice Location | |||||||||
Address1: | 20180 W 12 MILE RD | ||||||||
Address2: | STE 200 | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480765412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2482007756 | ||||||||
FaxNumber: | 2482813535 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2014 | ||||||||
LastUpdateDate: | 04/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AHSAN | ||||||||
AuthorizedOfficialFirstName: | MUHAMMED | ||||||||
AuthorizedOfficialMiddleName: | KAMRAN | ||||||||
AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
AuthorizedOfficialTelephone: | 9376733983 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301097463 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208VP0014X | 4301097463 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.