=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013385046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERVENTIONAL PAIN CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2015
-----------------------------------------------------
Last Update Date | 02/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27423 VAN DYKE AVE
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-757-4000
-----------------------------------------------------
Fax | 586-755-9880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27423 VAN DYKE AVE SUITE B
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-757-4000
-----------------------------------------------------
Fax | 586-755-9880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RAJENDRA BOTHRA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 586-757-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------