Provider Demographics
NPI:1215953815
Name:MICHIGAN PAIN MANAGEMENT SPECIALISTS PC
Entity type:Organization
Organization Name:MICHIGAN PAIN MANAGEMENT SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIESSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:517-364-5326
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:517-676-3438
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1800
Practice Address - Country:US
Practice Address - Phone:517-364-5326
Practice Address - Fax:517-364-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007347103TC0700X
103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M28210Medicare PIN
MI0C310310OtherBCBSM
MI0C36404Medicare PIN