Healthcare Provider Details

I. General information

NPI: 1124247119
Provider Name (Legal Business Name): INTERVENTIONAL PAIN MANAGEMENT PHYSICIANS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 STONE OAK LOOP SUITE 103
SAN ANTONIO TX
78258-3511
US

IV. Provider business mailing address

19141 STONE OAK PKWY STE 104
SAN ANTONIO TX
78258-3367
US

V. Phone/Fax

Practice location:
  • Phone: 210-268-0129
  • Fax: 210-497-8333
Mailing address:
  • Phone: 210-268-0129
  • Fax: 210-314-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberJ5738
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LESLIE LONGORIA
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 210-268-0129