Healthcare Provider Details

I. General information

NPI: 1013385046
Provider Name (Legal Business Name): INTERVENTIONAL PAIN CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27423 VAN DYKE AVE
WARREN MI
48093-2867
US

IV. Provider business mailing address

27423 VAN DYKE AVE SUITE B
WARREN MI
48093-2867
US

V. Phone/Fax

Practice location:
  • Phone: 586-757-4000
  • Fax: 586-755-9880
Mailing address:
  • Phone: 586-757-4000
  • Fax: 586-755-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAJENDRA BOTHRA
Title or Position: OWNER
Credential: MD
Phone: 586-757-4000