NPIMap

Organization Active NPI

Haven Spine & Pain Center PLLC

  • Interventional Pain Medicine Physician
  • Grand Rapids, MI
National Provider Identifier
1053901314
Registry record updated Dec 9, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X
Legal business name
HAVEN SPINE & PAIN CENTER PLLC
Practice address
2680 Leonard St NE Ste 3
Grand Rapids, MI 49525-6902
Phone
(616) 364-4200
Fax
(616) 364-7347
NPI assigned
Jan 21, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 9, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jack Dillon
Title
Executive Director
Phone
(312) 505-1033

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine (Anesthesiology) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207LP2900X
Pain Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 208VP0000X
Interventional Pain Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 208VP0014X Primary

Addresses

Primary practice location

2680 Leonard St NE Ste 3
Grand Rapids, MI 49525-6902

Mailing address

2680 Leonard St NE Ste 3
Grand Rapids, MI 49525-6902
Phone (616) 364-4200

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210326001078 MI Part B Supplier - Clinic/Group Practice 9537576129 Receives reassigned benefits from 7 practitioners
Practice locations: Grand Rapids, MI

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2235865Haven Spine + Pain2680 Leonard Street NE Suite 3, Grand Rapids, MI 49525Certificate of waiverSep 12, 2027

National Provider Directory

National Provider Directory

Locations

2680 Leonard St NE
Ste 3
Grand Rapids, MI 49525
Phone (616) 317-7246

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1611187200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1639008000000",
    "number": "1053901314",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2680 LEONARD ST NE STE 3",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495256902",
            "telephone_number": "616-364-4200",
            "fax_number": "616-364-7347"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2680 LEONARD ST NE STE 3",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495256902",
            "telephone_number": "616-364-4200",
            "fax_number": "616-364-7347"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HAVEN SPINE & PAIN CENTER PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-01-21",
        "last_updated": "2021-12-09",
        "certification_date": "2021-12-09",
        "status": "A",
        "authorized_official_last_name": "DILLON",
        "authorized_official_first_name": "JACK",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "312-505-1033"
    },
    "taxonomies": [
        {
            "code": "207LP2900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Anesthesiology, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Pain Medicine, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0014X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 9, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.