Provider Demographics
NPI:1366841587
Name:ROSWELL PROCEDURAL MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:ROSWELL PROCEDURAL MEDICINE ASSOCIATES
Other - Org Name:SOUTHWEST PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:DELILLO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, ARNP
Authorized Official - Phone:817-966-2762
Mailing Address - Street 1:PO BOX 2626
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2626
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:817-423-9060
Practice Address - Street 1:7451 CHAPEL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7090
Practice Address - Country:US
Practice Address - Phone:817-294-7444
Practice Address - Fax:817-423-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01308367500000X
TX514647367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8755UEOtherBCBS
TX126047304Medicaid
TX1013008721OtherNPI (INDIVIDUAL)
TX84396COtherBCBS (PERSONAL)
TX00C37JOtherBCBS (METRO C.R.N.A. SERVICES, INC)
TX006995701 (CORP)Medicaid
TX1245314640OtherNPI (METRO CRNA SERVICES, INC)
TX278429YMCVMedicare PIN
TX84396COtherBCBS (PERSONAL)
TX006995701 (CORP)Medicaid