Provider Demographics
NPI:1194180901
Name:MICHIGAN PAIN&SPINE CLINIC PLLC
Entity Type:Organization
Organization Name:MICHIGAN PAIN&SPINE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRUTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-495-7200
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:SUITE 6B, UNIVERSITY HEALTH CENTER
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-495-7200
Mailing Address - Fax:313-495-7104
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 6B, UNIVERSITY HEALTH CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-495-7200
Practice Address - Fax:313-495-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086330261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain