=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316244205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INCLUSIVE PAIN MANAGEMENT SPECIALISTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2011
-----------------------------------------------------
Last Update Date | 09/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 N BISHOP AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75208-4335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-942-5673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 N BISHOP AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75208-4335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-942-5673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN/PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT ABBATE
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 713-900-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | N4873
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | N4873
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | N4873
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------