Provider Demographics
NPI:1518087386
Name:NORTHERN MICHIGAN PAIN SPECIALISTS PC
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN PAIN SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FUCHS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-4650
Mailing Address - Street 1:1420 PLAZA DR.
Mailing Address - Street 2:STE 2B
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9421
Mailing Address - Country:US
Mailing Address - Phone:231-487-4650
Mailing Address - Fax:231-487-4613
Practice Address - Street 1:1420 PLAZA DR.
Practice Address - Street 2:STE 2B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9421
Practice Address - Country:US
Practice Address - Phone:231-487-4650
Practice Address - Fax:231-487-4613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003291208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4122280 TYPE 10Medicaid
MIG86360Medicare UPIN
MI4122280 TYPE 10Medicaid