Provider Demographics
NPI:1427571355
Name:INTERVENTIONAL SPINE & PAIN, LLP
Entity Type:Organization
Organization Name:INTERVENTIONAL SPINE & PAIN, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEBALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-218-2484
Mailing Address - Street 1:ATTN: CYNTHIA REYNOLDS CREDENTIALER
Mailing Address - Street 2:18670 GRAPHICS DR. STE. 100
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6653
Mailing Address - Country:US
Mailing Address - Phone:708-228-4262
Mailing Address - Fax:708-314-7505
Practice Address - Street 1:8222 DOUGLAS AVENUE
Practice Address - Street 2:STE. 890
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-7036
Practice Address - Country:US
Practice Address - Phone:214-888-3900
Practice Address - Fax:972-681-8727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-23
Last Update Date:2018-12-07
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
7083350002OtherADDITIONAL DME