Provider Demographics
NPI:1568658920
Name:ALLIED PAIN MANAGEMENT CLINIC P.A.
Entity Type:Organization
Organization Name:ALLIED PAIN MANAGEMENT CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-6078
Mailing Address - Street 1:5201 S BROADWAY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3748
Mailing Address - Country:US
Mailing Address - Phone:903-595-6078
Mailing Address - Fax:903-509-2545
Practice Address - Street 1:5201 S BROADWAY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3748
Practice Address - Country:US
Practice Address - Phone:903-595-6078
Practice Address - Fax:903-509-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302391041C0700X
TXDC5099111N00000X
TXH4166207Q00000X, 207QG0300X, 207QH0002X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT84775Medicare UPIN
TX850135Medicare PIN
TX8F0136Medicare PIN
TX0082536Medicare UPIN