Healthcare Provider Details

I. General information

NPI: 1467418574
Provider Name (Legal Business Name): MICHIGAN PAIN CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 EAST PARIS AVE SE SUITE 200
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

5555 GLENWOOD HILLS PKWY SE STE 2
GRAND RAPIDS MI
49512-2091
US

V. Phone/Fax

Practice location:
  • Phone: 616-285-1377
  • Fax: 616-285-1006
Mailing address:
  • Phone: 616-940-2662
  • Fax: 616-940-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARK LOUIS GOSTINE
Title or Position: PRESIDENT
Credential: MD
Phone: 616-285-1377