Provider Demographics
NPI:1326091513
Name:PAIN TREATMENT CENTERS OF MICHIGAN LLC
Entity Type:Organization
Organization Name:PAIN TREATMENT CENTERS OF MICHIGAN LLC
Other - Org Name:MATRIX SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:4450 FASHION SQUARE BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1251
Mailing Address - Country:US
Mailing Address - Phone:989-790-7950
Mailing Address - Fax:989-790-1770
Practice Address - Street 1:4450 FASHION SQUARE BLVD
Practice Address - Street 2:STE 200
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1251
Practice Address - Country:US
Practice Address - Phone:989-790-7950
Practice Address - Fax:989-790-1770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1010000059261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23C0001071Medicare Oscar/Certification
MI0P39490Medicare PIN