Basic Information
| Provider Information | |||||||||
| NPI: | 1407358641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL PAIN SPECIALISTS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5010 CRENSHAW RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775054615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819912200 | ||||||||
| FaxNumber: | 2819917700 | ||||||||
| Practice Location | |||||||||
| Address1: | 16840 BUCCANEER LN STE 202 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770582563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819912200 | ||||||||
| FaxNumber: | 2819917700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2018 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | DIETER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2819444701 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.