MEDICARE: CENTRAL TEXAS PAIN CENTER SOUTH 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	208VP0014X	Interventional Pain Medicine Physician	L9364	TX

General Provider Information

NPI Number	:	1821341355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL TEXAS PAIN CENTER SOUTH PLLC

Provider Business Mailing Address
First Line	:	PO BOX 208354
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-8354
Country	:	US
Telephone Number	:	512-485-7208
Fax Number	:	844-364-8678

Provider Business Practice Location Address
First Line	:	250 E BASSE RD STE 207
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-8409
Country	:	US
Telephone Number	:	210-614-9955
Fax Number	:	210-614-9966

Authorized Official
Title or Position	:	MD/OWNER
Name	:	DR. DANIEL FREDERICK
Credential	:	MD
Telephone Number	:	512-485-7208

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	09/29/2021

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