MEDICARE: SOUTHWESTERN PAIN INSTITUTE, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	367500000X	Certified Registered Nurse Anesthetist
3	207LP2900X	Pain Medicine (Anesthesiology) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0021DM	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1386786564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWESTERN PAIN INSTITUTE, PA

Provider Business Mailing Address
First Line	:	PO BOX 803311
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75380-3311
Country	:	US
Telephone Number	:	972-980-4400
Fax Number	:	972-980-4100

Provider Business Practice Location Address
First Line	:	5744 LYNDON B JOHNSON FWY
Second Line	:	SUITE 175
City	:	DALLAS
State	:	TX
Zip	:	75240-6322
Country	:	US
Telephone Number	:	972-980-4400
Fax Number	:	972-980-4100

Authorized Official
Title or Position	:	PAIN MANAGEMENT
Name	:	DR. DANIEL SHALEV
Credential	:	M.D.
Telephone Number	:	972-980-4400

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	05/19/2009

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