Provider Demographics
NPI:1114113669
Name:INTERVENTIONAL PAIN MANAGEMENT, PA
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN MANAGEMENT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-560-2222
Mailing Address - Street 1:3312 N UNIVERSITY DR
Mailing Address - Street 2:SUITE J
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2637
Mailing Address - Country:US
Mailing Address - Phone:936-560-2222
Mailing Address - Fax:936-569-1788
Practice Address - Street 1:3312 N UNIVERSITY DR
Practice Address - Street 2:SUITE J
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2637
Practice Address - Country:US
Practice Address - Phone:936-560-2222
Practice Address - Fax:936-569-1788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERVENTIONAL PAIN MANAGEMENT, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8185207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184657801Medicaid
DF4810OtherPALMETTO GBA
DF4810OtherPALMETTO GBA
TXG14120Medicare UPIN