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General NPI Number Information
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NPI Number | 1538597877
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Entity Type | Organization
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Legal Business Name | MICHIGAN PAIN&SPINE CLINIC PLLC
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Dates
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Enumeration Date | 10/23/2013
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Last Update Date | 02/03/2019
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Provider Practice Location Address
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Address Line | 6255 INKSTER RD STE 105
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City | GARDEN CITY
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State | MI
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Zip | 48135-2538
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Country | US
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Telephone | 313-831-4800
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Fax | 313-495-7104
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Provider Business Mailing Address
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Address Line | 6255 INKSTER RD STE 105
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City | GARDEN CITY
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State | MI
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Zip | 48135-2538
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Country | US
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Telephone | 313-831-4800
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Fax | 313-495-7104
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Authorized Official
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Title or Position | PRESIDENT
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Name | SRUTHI KONDUR
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Credential | MD
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Telephone | 313-831-4800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | 4301086330
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License Number State | MI
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