Provider Demographics
NPI:1164877692
Name:INTERVENTIONAL PAIN & ANESTHESIA CONSULTANTS PLLC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN & ANESTHESIA CONSULTANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:T
Authorized Official - Last Name:ITTIARA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-604-0017
Mailing Address - Street 1:416 JAMES CIR
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-4545
Mailing Address - Country:US
Mailing Address - Phone:734-604-0017
Mailing Address - Fax:
Practice Address - Street 1:20100 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2647
Practice Address - Country:US
Practice Address - Phone:734-604-0017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017919207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty