Provider Demographics
NPI:1780071167
Name:PAIN MANAGEMENT GROUP PLLC
Entity type:Organization
Organization Name:PAIN MANAGEMENT GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-572-9020
Mailing Address - Street 1:PO BOX 33791
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-3781
Mailing Address - Country:US
Mailing Address - Phone:419-721-6358
Mailing Address - Fax:800-261-0301
Practice Address - Street 1:229 W. MAIN CROSS ST
Practice Address - Street 2:STE 58
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840
Practice Address - Country:US
Practice Address - Phone:419-721-6358
Practice Address - Fax:800-261-0301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAIN MANAGEMENT GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-23
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780071167Medicaid