MEDICARE: PAIN SPECIALISTS OF TEXAS, LP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center	L5075,K3744	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0093NJ	OTHER	TX	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1548285000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN SPECIALISTS OF TEXAS, LP

Provider Business Mailing Address
First Line	:	1759 BROAD PARK CIRCLE STREET SOUTH
Second Line	:	SUITE 101
City	:	MANSFIELD
State	:	TX
Zip	:	76063
Country	:	US
Telephone Number	:	682-518-0682
Fax Number	:	682-518-1334

Provider Business Practice Location Address
First Line	:	1759 BROAD PARK CIRCLE STREET SOUTH
Second Line	:	SUITE 101
City	:	MANSFIELD
State	:	TX
Zip	:	75052-3073
Country	:	US
Telephone Number	:	682-518-0682
Fax Number	:	682-518-1334

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	LYNNE GEORGE
Credential	:
Telephone Number	:	972-606-8980

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	04/26/2011

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