Basic Information
Provider Information | |||||||||
NPI: | 1063655124 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PYRAMID PAIN AND REHAB P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTH TEXAS COMPREHENSIVE SPINE AND PAIN CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 SARA SWAMY DR STE 220 | ||||||||
Address2: |   | ||||||||
City: | SHERMAN | ||||||||
State: | TX | ||||||||
PostalCode: | 750903124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 0398921999 | ||||||||
FaxNumber: | 9038926999 | ||||||||
Practice Location | |||||||||
Address1: | 1001 SARA SWAMY DR. | ||||||||
Address2: | STE 220 | ||||||||
City: | SHERMAN | ||||||||
State: | TX | ||||||||
PostalCode: | 750903124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9038921999 | ||||||||
FaxNumber: | 9038926999 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2009 | ||||||||
LastUpdateDate: | 11/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VATTAM | ||||||||
AuthorizedOfficialFirstName: | SREENADHA | ||||||||
AuthorizedOfficialMiddleName: | R. | ||||||||
AuthorizedOfficialTitleorPosition: | MD | ||||||||
AuthorizedOfficialTelephone: | 9038921999 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 11/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | M2851 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X |   | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | DP2969 | 01 | TX | RR MEDICARE | OTHER | 6514340001 | 01 | TX | NSC | OTHER |