Provider Demographics
NPI:1962571125
Name:SPINE SPORTS & OCCUPATIONAL MEDICINE P.C.
Entity type:Organization
Organization Name:SPINE SPORTS & OCCUPATIONAL MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FATMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:NISKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-928-0700
Mailing Address - Street 1:15636 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2513
Mailing Address - Country:US
Mailing Address - Phone:313-928-0700
Mailing Address - Fax:313-928-0701
Practice Address - Street 1:15636 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2513
Practice Address - Country:US
Practice Address - Phone:313-928-0700
Practice Address - Fax:313-928-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H217480OtherBCBSM
MI0H217480OtherBCBSM