Provider Demographics
NPI:1467418574
Name:MICHIGAN PAIN CONSULTANTS PC
Entity Type:Organization
Organization Name:MICHIGAN PAIN CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GOSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-285-1377
Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 EAST PARIS AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700D160000OtherBLUE CROSS BLUE SHIELD
MI700D160000OtherBLUE CROSS BLUE SHIELD
MI0P03810Medicare PIN
MI0N82570Medicare PIN
MI0D16000Medicare PIN
MI0N70920Medicare PIN
MI0770900Medicare PIN