Basic Information
Provider Information | |||||||||
NPI: | 1376066126 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTERVENTIONAL SPINE AND PAIN, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17051 DALLAS PKWY STE 300 | ||||||||
Address2: |   | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750017105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2148883900 | ||||||||
FaxNumber: | 2148883901 | ||||||||
Practice Location | |||||||||
Address1: | 17501 NORTH DALLAS PARKWAY | ||||||||
Address2: | SUITE 300 | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 75001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2148883900 | ||||||||
FaxNumber: | 2148883901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2017 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEDOUX | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2148883900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.