Basic Information
| Provider Information | |||||||||
| NPI: | 1205453917 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE AND PAIN ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1889 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473081889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 YORK DR | ||||||||
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| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751152083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4943130040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2020 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | PRITESH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4943130040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.