1427571355 NPI number — INTERVENTIONAL SPINE & PAIN, LLP

Table of content: (NPI 1427571355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427571355 NPI number — INTERVENTIONAL SPINE & PAIN, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL SPINE & PAIN, LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427571355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ATTN: CYNTHIA REYNOLDS CREDENTIALER
Provider Second Line Business Mailing Address:
18670 GRAPHICS DR. STE. 100
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-6653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-228-4262
Provider Business Mailing Address Fax Number:
708-314-7505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8222 DOUGLAS AVENUE
Provider Second Line Business Practice Location Address:
STE. 890
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75225-7036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-888-3900
Provider Business Practice Location Address Fax Number:
972-681-8727
Provider Enumeration Date:
07/23/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ZEBALLOS
Authorized Official First Name:
PABLO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-218-2484

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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