Healthcare Provider Details

I. General information

NPI: 1740645381
Provider Name (Legal Business Name): INTEGRATED SPINE AND PAIN CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 S. PARK STREET
KALAMAZOO MI
49001
US

IV. Provider business mailing address

1324 S. PARK STREET
KALAMAZOO MI
49001
US

V. Phone/Fax

Practice location:
  • Phone: 269-381-2800
  • Fax:
Mailing address:
  • Phone: 269-381-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301062116
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberME120998
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704241734
License Number StateMI

VIII. Authorized Official

Name: NAZEM ABDELFATTAH
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 269-381-2800