Healthcare Provider Details

I. General information

NPI: 1649707548
Provider Name (Legal Business Name): INTEGRATED HEADACHE AND PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 05/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W FAIRMONT PKWY STE D
LA PORTE TX
77571-6314
US

IV. Provider business mailing address

1120 NASA PKWY 220Q
HOUSTON TX
77058-3342
US

V. Phone/Fax

Practice location:
  • Phone: 832-858-6531
  • Fax:
Mailing address:
  • Phone:
  • Fax: 832-240-3370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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

VIII. Authorized Official

Name: MOHAMAD AZZAM
Title or Position: OWNER
Credential:
Phone: 832-858-6531