Provider Demographics
NPI:1275759540
Name:PAIN & NEUROMUSCULAR CLINIC OF TEXAS , P.A.
Entity Type:Organization
Organization Name:PAIN & NEUROMUSCULAR CLINIC OF TEXAS , P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:THEAGENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-826-2311
Mailing Address - Street 1:PO BOX 29097
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-0097
Mailing Address - Country:US
Mailing Address - Phone:210-826-2311
Mailing Address - Fax:210-826-2641
Practice Address - Street 1:6100 BANDERA RD
Practice Address - Street 2:710
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1652
Practice Address - Country:US
Practice Address - Phone:210-826-2311
Practice Address - Fax:210-826-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7690174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0074DJOtherBLUE CROSS BLUE SHIELD
TXF92342Medicare UPIN
TX00827NMedicare ID - Type Unspecified