Basic Information
Provider Information | |||||||||
NPI: | 1053609313 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PASADENA PAIN MANAGEMENT CONSULTANTS, PA. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INTERVENTIONAL PAIN SPECIALISTS - TEXAS CITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5607 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | TX | ||||||||
PostalCode: | 775085607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2819912200 | ||||||||
FaxNumber: | 2819917700 | ||||||||
Practice Location | |||||||||
Address1: | 7111 MEDICAL CENTER DRIVE | ||||||||
Address2: | STE. #111 | ||||||||
City: | TEXAS CITY | ||||||||
State: | TX | ||||||||
PostalCode: | 77591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2819912200 | ||||||||
FaxNumber: | 2819917700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2011 | ||||||||
LastUpdateDate: | 03/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REYES | ||||||||
AuthorizedOfficialFirstName: | JOSE | ||||||||
AuthorizedOfficialMiddleName: | R. | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2819912200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | J9299 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | J9299 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | J9299 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.