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General NPI Number Information
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NPI Number | 1649415100
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Entity Type | Organization
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Legal Business Name | PREMIER SPINAL PAIN MANAGEMENT CENTER, PLLC
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Dates
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Enumeration Date | 12/11/2008
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Last Update Date | 09/06/2009
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Provider Practice Location Address
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Address Line | 15101 SOUTHFIELD RD SUITE 103
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City | ALLEN PARK
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State | MI
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Zip | 48101-2697
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Country | US
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Telephone | 313-381-1650
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Fax | 313-381-1652
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Provider Business Mailing Address
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Address Line | 15101 SOUTHFIELD RD SUITE 103
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City | ALLEN PARK
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State | MI
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Zip | 48101-2697
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Country | US
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Telephone | 313-381-1650
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Fax | 313-381-1652
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Authorized Official
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Title or Position | OWNER
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Name | DR. GAYATRI GARG
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Credential | M.D.
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Telephone | 313-381-1650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | 4301042515
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License Number State | MI
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