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General NPI Number Information
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NPI Number | 1962571125
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Entity Type | Organization
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Legal Business Name | SPINE SPORTS & OCCUPATIONAL MEDICINE P.C.
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 02/02/2024
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Provider Practice Location Address
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Address Line | 15636 SOUTHFIELD RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-2513
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Country | US
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Telephone | 313-928-0700
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Fax | 313-928-0701
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Provider Business Mailing Address
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Address Line | 15636 SOUTHFIELD RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-2513
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Country | US
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Telephone | 313-928-0700
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Fax | 313-928-0701
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Authorized Official
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Title or Position | OWNER
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Name | MRS. FATMEH NISKAR
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Credential |
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Telephone | 313-928-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0401X
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Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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