Provider Demographics
NPI:1740645381
Name:INTEGRATED SPINE AND PAIN CENTER PLLC
Entity type:Organization
Organization Name:INTEGRATED SPINE AND PAIN CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:NAZEM
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDELFATTAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-381-2800
Mailing Address - Street 1:1324 S. PARK STREET
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001
Mailing Address - Country:US
Mailing Address - Phone:269-381-2800
Mailing Address - Fax:
Practice Address - Street 1:1324 S. PARK STREET
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001
Practice Address - Country:US
Practice Address - Phone:269-381-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062116207Q00000X
MIME120998332B00000X
MI4704241734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI9834Medicare PIN