Healthcare Provider Details

I. General information

NPI: 1871369744
Provider Name (Legal Business Name): SOUTHFIELD CENTER FOR INTERGRATED MUSCULOSKELETAL INJURY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26400 LAHSER RD STE 100
SOUTHFIELD MI
48033-2672
US

IV. Provider business mailing address

602 VIENTO DE AVILA
TAMPA FL
33613-5229
US

V. Phone/Fax

Practice location:
  • Phone: 917-449-7582
  • Fax:
Mailing address:
  • Phone: 917-449-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT SUPER
Title or Position: PRESIDENT
Credential: DC
Phone: 917-449-7582