Basic Information
| Provider Information | |||||||||
| NPI: | 1780071167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN MANAGEMENT GROUP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33791 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482323781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197216358 | ||||||||
| FaxNumber: | 8002610301 | ||||||||
| 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: | 04/23/2015 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | HECKER | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6145729020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PAIN MANAGEMENT GROUP LLC | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1780071167 | 05 | MI | MEDICAID |