Provider Demographics
NPI:1578184685
Name:PAIN MANAGEMENT PHYSICIANS OF DALLAS, PLLC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT PHYSICIANS OF DALLAS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:T
Authorized Official - Last Name:KRAUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-948-7700
Mailing Address - Street 1:1411 N BECKLEY AVE STE 152
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1586
Mailing Address - Country:US
Mailing Address - Phone:214-948-7700
Mailing Address - Fax:214-948-7701
Practice Address - Street 1:8404 STERLING ST STE B
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2527
Practice Address - Country:US
Practice Address - Phone:214-948-7700
Practice Address - Fax:214-948-7701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAIN MANAGEMENT PHYSICIANS OF DALLAS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
45D2145472OtherCLIA
45D2016038OtherCLIA WAIVED