Provider Demographics
NPI:1912724865
Name:SUPERIOR INTERVENTIONAL PAIN PLLC
Entity type:Organization
Organization Name:SUPERIOR INTERVENTIONAL PAIN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-415-2233
Mailing Address - Street 1:1190 E 12 MILE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2648
Mailing Address - Country:US
Mailing Address - Phone:248-629-6242
Mailing Address - Fax:
Practice Address - Street 1:1190 E 12 MILE RD STE 2
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2648
Practice Address - Country:US
Practice Address - Phone:248-629-6242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain