Provider Demographics
NPI:1568889442
Name:BLUE WATER PAIN SPECIALISTS PC
Entity Type:Organization
Organization Name:BLUE WATER PAIN SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:DURGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-792-7029
Mailing Address - Street 1:538 CHASE LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2363
Mailing Address - Country:US
Mailing Address - Phone:248-792-7029
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty