Provider Demographics
NPI:1376066126
Name:INTERVENTIONAL SPINE AND PAIN, LLP
Entity Type:Organization
Organization Name:INTERVENTIONAL SPINE AND PAIN, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDOUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-888-3900
Mailing Address - Street 1:17051 DALLAS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-7105
Mailing Address - Country:US
Mailing Address - Phone:214-888-3900
Mailing Address - Fax:214-888-3901
Practice Address - Street 1:17501 NORTH DALLAS PARKWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001
Practice Address - Country:US
Practice Address - Phone:214-888-3900
Practice Address - Fax:214-888-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-24
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7083350002OtherADDITIONAL DME