Healthcare Provider Details

I. General information

NPI: 1962571125
Provider Name (Legal Business Name): SPINE SPORTS & OCCUPATIONAL MEDICINE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15636 SOUTHFIELD RD
ALLEN PARK MI
48101-2513
US

IV. Provider business mailing address

15636 SOUTHFIELD RD
ALLEN PARK MI
48101-2513
US

V. Phone/Fax

Practice location:
  • Phone: 313-928-0700
  • Fax: 313-928-0701
Mailing address:
  • Phone: 313-928-0700
  • Fax: 313-928-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MRS. FATMEH NISKAR
Title or Position: OWNER
Credential:
Phone: 313-928-0700