Healthcare Provider Details

I. General information

NPI: 1821597659
Provider Name (Legal Business Name): ADVANCE SPINE & PAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24715 LITTLE MACK AVE STE 100
SAINT CLAIR SHORES MI
48080-3207
US

IV. Provider business mailing address

10 LOCHMOOR BLVD
GROSSE POINTE SHORES MI
48236-1748
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER AJLOUNI
Title or Position: PHYSICIAN
Credential: MD
Phone: 313-407-4422