Provider Demographics
NPI:1225302821
Name:PAIN CLINIC MANAGEMENT GROUP, PLLC
Entity Type:Organization
Organization Name:PAIN CLINIC MANAGEMENT GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-978-7250
Mailing Address - Street 1:PO BOX 772211
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2211
Mailing Address - Country:US
Mailing Address - Phone:800-444-6110
Mailing Address - Fax:
Practice Address - Street 1:35634 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4288
Practice Address - Country:US
Practice Address - Phone:586-978-7250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty