MEDICARE: SOUTHEAST MICHIGAN INTERVENTIONAL PAIN SPECIALISTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1275280711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST MICHIGAN INTERVENTIONAL PAIN SPECIALISTS

Provider Business Mailing Address
First Line	:	2841 MONROE ST FL 2
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3492
Country	:	US
Telephone Number	:	313-998-8662
Fax Number	:	313-867-4581

Provider Business Practice Location Address
First Line	:	2841 MONROE ST FL 2
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3492
Country	:	US
Telephone Number	:	313-998-8662
Fax Number	:	313-867-4581

Authorized Official
Title or Position	:	OWNER
Name	:	BRYAN S TOMA
Credential	:	MD
Telephone Number	:	248-470-8912

Provider Enumeration Date	:	03/04/2022
Last Update Date	:	11/21/2022

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