Healthcare Provider Details

I. General information

NPI: 1376066126
Provider Name (Legal Business Name): INTERVENTIONAL SPINE AND PAIN, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17501 NORTH DALLAS PARKWAY SUITE 300
ADDISON TX
75001
US

IV. Provider business mailing address

17051 DALLAS PKWY STE 300
ADDISON TX
75001-7105
US

V. Phone/Fax

Practice location:
  • Phone: 214-888-3900
  • Fax: 214-888-3901
Mailing address:
  • Phone: 214-888-3900
  • Fax: 214-888-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARK LEDOUX
Title or Position: OWNER
Credential: MD
Phone: 214-888-3900