Healthcare Provider Details

I. General information

NPI: 1164877692
Provider Name (Legal Business Name): INTERVENTIONAL PAIN & ANESTHESIA CONSULTANTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20100 OUTER DR
DEARBORN MI
48124-2647
US

IV. Provider business mailing address

416 JAMES CIR
ROYAL OAK MI
48067-4545
US

V. Phone/Fax

Practice location:
  • Phone: 734-604-0017
  • Fax:
Mailing address:
  • Phone: 734-604-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number5101017919
License Number StateMI

VIII. Authorized Official

Name: DR. BRYANT T ITTIARA
Title or Position: PRESIDENT
Credential: D.O.
Phone: 734-604-0017