Provider Demographics
NPI:1124247119
Name:INTERVENTIONAL PAIN MANAGEMENT PHYSICIANS PA
Entity type:Organization
Organization Name:INTERVENTIONAL PAIN MANAGEMENT PHYSICIANS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGORIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-268-0129
Mailing Address - Street 1:19141 STONE OAK PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3367
Mailing Address - Country:US
Mailing Address - Phone:210-268-0129
Mailing Address - Fax:210-314-4609
Practice Address - Street 1:110 STONE OAK LOOP
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3511
Practice Address - Country:US
Practice Address - Phone:210-268-0129
Practice Address - Fax:210-497-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5738174400000X
208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080538401Medicaid
TX080538401Medicaid