Healthcare Provider Details

I. General information

NPI: 1730458381
Provider Name (Legal Business Name): NEURIOM, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4007 MCCULLOUGH AVE #243
SAN ANTONIO TX
78212
US

IV. Provider business mailing address

4007 MCCULLOUGH AVE #243
SAN ANTONIO TX
78212
US

V. Phone/Fax

Practice location:
  • Phone: 210-714-5534
  • Fax: 210-598-2815
Mailing address:
  • Phone: 210-714-5534
  • Fax: 210-566-1330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALISSA FISHER
Title or Position: ENROLLMENT COMPLIANCE OFFICER
Credential:
Phone: 210-598-4240