1780917179 NPI number — INTERVENTIONAL PAIN SOLUTIONS, PA.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780917179 NPI number — INTERVENTIONAL PAIN SOLUTIONS, PA.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN SOLUTIONS, PA.
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:
1780917179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 WEST ROYAL LANE
Provider Second Line Business Mailing Address:
#230
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-956-5541
Provider Business Mailing Address Fax Number:
972-956-5504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 WEST ROYAL LANE
Provider Second Line Business Practice Location Address:
#230
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-956-5541
Provider Business Practice Location Address Fax Number:
972-956-5504
Provider Enumeration Date:
09/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MAWBY
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
NICHOLE
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
972-956-5541

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  M6482 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6617390001 . This is a "PTAN FOR DME" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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