MEDICARE: MICHIGAN PAIN MANAGEMENT CONSULTANTS, PC

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	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1922041755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN PAIN MANAGEMENT CONSULTANTS, PC

Provider Business Mailing Address
First Line	:	255 W MICHIGAN AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-2218
Country	:	US
Telephone Number	:	517-787-6440
Fax Number	:	517-787-4146

Provider Business Practice Location Address
First Line	:	22255 GREENFIELD RD STE 500
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-3734
Country	:	US
Telephone Number	:	248-849-3142
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	JOHN TRAYLOR
Credential	:	M.D.
Telephone Number	:	248-849-3192

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	04/13/2018

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