Healthcare Provider Details

I. General information

NPI: 1205453917
Provider Name (Legal Business Name): SPINE AND PAIN ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 YORK DR
DESOTO TX
75115-2083
US

IV. Provider business mailing address

PO BOX 1889
MUNCIE IN
47308-1889
US

V. Phone/Fax

Practice location:
  • Phone: 494-313-0040
  • Fax:
Mailing address:
  • Phone: 765-284-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PRITESH PATEL
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 494-313-0040