Provider Demographics
NPI:1477703833
Name:PAIN AND REHABILITATIVE MEDICINE CENTER P C
Entity type:Organization
Organization Name:PAIN AND REHABILITATIVE MEDICINE CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:GWENETH
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-539-8446
Mailing Address - Street 1:31800 NORTHWESTERN HWY
Mailing Address - Street 2:STE 120
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1655
Mailing Address - Country:US
Mailing Address - Phone:248-539-8446
Mailing Address - Fax:248-539-8447
Practice Address - Street 1:31800 NORTHWESTERN HWY
Practice Address - Street 2:STE 120
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1655
Practice Address - Country:US
Practice Address - Phone:248-539-8446
Practice Address - Fax:248-539-8447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE77894Medicare UPIN
MI0636591Medicare PIN