MEDICARE: PREMIER PAIN CONSULTANTS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician
2	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1336584093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PAIN CONSULTANTS, PLLC

Provider Business Mailing Address
First Line	:	2425 BABCOCK RD STE 108
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-4899
Country	:	US
Telephone Number	:	210-616-9400
Fax Number	:	210-616-9402

Provider Business Practice Location Address
First Line	:	11212 STATE HIGHWAY 151 STE 360
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-4504
Country	:	US
Telephone Number	:	210-616-9400
Fax Number	:	210-616-9402

Authorized Official
Title or Position	:	OWNER
Name	:	DMITRIY BUYANOV
Credential	:	M.D.
Telephone Number	:	210-616-9400

Provider Enumeration Date	:	05/07/2013
Last Update Date	:	01/13/2014

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