Basic Information
| Provider Information | |||||||||
| NPI: | 1427571355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL SPINE & PAIN, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | ATTN: CYNTHIA REYNOLDS CREDENTIALER | ||||||||
| Address2: | 18670 GRAPHICS DR. STE. 100 | ||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604776653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082284262 | ||||||||
| FaxNumber: | 7083147505 | ||||||||
| Practice Location | |||||||||
| Address1: | 8222 DOUGLAS AVENUE | ||||||||
| Address2: | STE. 890 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752257036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148883900 | ||||||||
| FaxNumber: | 9726818727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2017 | ||||||||
| LastUpdateDate: | 12/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | ZEBALLOS | ||||||||
| AuthorizedOfficialFirstName: | PABLO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2192182484 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.