1669420345 NPI number — ALLIED PAIN MANAGEMENT CLINIC, P.A.

Table of content: (NPI 1669420345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669420345 NPI number — ALLIED PAIN MANAGEMENT CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIED PAIN MANAGEMENT CLINIC, P.A.
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:
1669420345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 131567
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75713-1567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-595-6078
Provider Business Mailing Address Fax Number:
903-509-2545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5201 S BROADWAY AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-3748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-595-6078
Provider Business Practice Location Address Fax Number:
903-509-2545
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLANTON
Authorized Official First Name:
AMY
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
PROVIDER RELATIONS
Authorized Official Telephone Number:
903-595-6078

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  H4166 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: 30239 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 111NX0800X , with the licence number: DC5099 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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