Provider Demographics
NPI:1104863059
Name:BEAUMONT SPINE PAIN AND SPORTS MEDICINCE
Entity type:Organization
Organization Name:BEAUMONT SPINE PAIN AND SPORTS MEDICINCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMESNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-886-1900
Mailing Address - Street 1:5220 EASTEX FWY
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77708-5320
Mailing Address - Country:US
Mailing Address - Phone:409-924-8600
Mailing Address - Fax:
Practice Address - Street 1:5220 EASTEX FWY
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77708-5320
Practice Address - Country:US
Practice Address - Phone:409-924-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3137208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00526WMedicare ID - Type Unspecified