Healthcare Provider Details

I. General information

NPI: 1831907575
Provider Name (Legal Business Name): SKYLINE PAIN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2024
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUTTERCUP CREEK BLVD STE 115
CEDAR PARK TX
78613-3701
US

IV. Provider business mailing address

200 BUTTERCUP CREEK BLVD STE 115
CEDAR PARK TX
78613-3701
US

V. Phone/Fax

Practice location:
  • Phone: 512-777-1211
  • Fax: 512-777-1214
Mailing address:
  • Phone: 512-777-1211
  • Fax: 512-777-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID KIM
Title or Position: MANAGER
Credential:
Phone: 512-777-1211