NPIMap

Organization Active NPI

Blue Water Pain Specialists PC

  • Pain Medicine Physician
  • Detroit, MI
National Provider Identifier
1568889442
Registry record updated Nov 15, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Medicine PhysicianTaxonomy code 208VP0000X
Legal business name
BLUE WATER PAIN SPECIALISTS PC
Practice address
22101 Moross Rd
Detroit, MI 48236-2148
Phone
(313) 343-4000
NPI assigned
Mar 28, 2014
Last updated
Nov 15, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 15, 2017

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

Authorized official

Name
Bassam E. Durgham, MDNPI 1871520247
Title
Treasurer
Phone
(248) 792-7029

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine Physician 208VP0000X NU Primary

Addresses

Primary practice location

22101 Moross Rd
Detroit, MI 48236-2148

Mailing address

538 Chase LN
Bloomfield Hills, MI 48304-2363
Phone (248) 792-7029

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140506000340 MI Part B Supplier - Clinic/Group Practice 9537392188 Receives reassigned benefits from 8 practitioners
Practice locations: Macomb Township, MI; Saint Clair Shores, MI; Rochester Hills, MI; Macomb, MI; Detroit, MI; Clinton Township, MI

National Provider Directory

National Provider Directory

Locations

17700 23 Mile Rd
Ste 402
Macomb, MI 48044

22701 Hall Rd
Macomb, MI 48042
Phone (586) 260-4665

46591 Romeo Plank Rd
Ste 137
Macomb, MI 48044
Phone (313) 343-6840

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1395964800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1510704000000",
    "number": "1568889442",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "538 CHASE LN",
            "city": "BLOOMFIELD HILLS",
            "state": "MI",
            "postal_code": "483042363",
            "telephone_number": "248-792-7029"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "22101 MOROSS RD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482362148",
            "telephone_number": "313-343-4000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE WATER PAIN SPECIALISTS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-28",
        "last_updated": "2017-11-15",
        "status": "A",
        "authorized_official_last_name": "DURGHAM",
        "authorized_official_first_name": "BASSAM",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "TREASURER",
        "authorized_official_telephone_number": "248-792-7029",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208VP0000X",
            "taxonomy_group": "",
            "desc": "Pain Medicine, Pain Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Detroit, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.