Provider Demographics
NPI:1427585900
Name:MPM PROFESSIONAL LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:MPM PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-774-5061
Mailing Address - Street 1:7603 BRAUN BND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-2603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17331 IH 35 N STE 103
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-1273
Practice Address - Country:US
Practice Address - Phone:210-774-5061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-16
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7159208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
29430YWSLOtherMEDICARE