Basic Information
| Provider Information | |||||||||
| NPI: | 1760566749 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PASADENA PAIN MANAGEMENT CONSULTANTS, PA. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTERVENTIONAL PAIN SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5607 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775085607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819912200 | ||||||||
| FaxNumber: | 2819917700 | ||||||||
| Practice Location | |||||||||
| Address1: | 5010 CRENSHAW RD | ||||||||
| Address2: | STE. #130 | ||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775053047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819912200 | ||||||||
| FaxNumber: | 2819917700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REYES | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | RAMON | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR CEO | ||||||||
| AuthorizedOfficialTelephone: | 2819912200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 079696301 | 05 | TX | MEDICAID | 0004CG | 01 | TX | BCBS GROUP # | OTHER |