MEDICARE: OLYMPIC SPINE AND JOINT PLLC

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	208VP0014X	Interventional Pain Medicine Physician
2	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1861061749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPIC SPINE AND JOINT PLLC

Provider Business Mailing Address
First Line	:	10101 SOUTHWEST FWY STE 400
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77074-1134
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19875 SOUTHWEST FWY STE 110
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-3502
Country	:	US
Telephone Number	:	832-919-8080
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. DAVID EIDSELON
Credential	:	MD
Telephone Number	:	832-919-8080

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	08/05/2024

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