Provider Demographics
NPI:1649415100
Name:PREMIER SPINAL PAIN MANAGEMENT CENTER, PLLC
Entity type:Organization
Organization Name:PREMIER SPINAL PAIN MANAGEMENT CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYATRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GARG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-381-1650
Mailing Address - Street 1:15101 SOUTHFIELD RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2697
Mailing Address - Country:US
Mailing Address - Phone:313-381-1650
Mailing Address - Fax:313-381-1652
Practice Address - Street 1:15101 SOUTHFIELD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2697
Practice Address - Country:US
Practice Address - Phone:313-381-1650
Practice Address - Fax:313-381-1652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2009-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010425152085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty