Provider Demographics
NPI:1184863748
Name:INTEGRATIVE SPINE AND PAIN MANAGEMENT, PLLC
Entity Type:Organization
Organization Name:INTEGRATIVE SPINE AND PAIN MANAGEMENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:KOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-606-7181
Mailing Address - Street 1:4632 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8067
Mailing Address - Country:US
Mailing Address - Phone:810-606-7181
Mailing Address - Fax:810-606-7174
Practice Address - Street 1:12851 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-8506
Practice Address - Country:US
Practice Address - Phone:810-606-7181
Practice Address - Fax:810-606-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty