Provider Demographics
NPI:1780195412
Name:OLYMPUS PAIN AND ORTHOPEDICS
Entity Type:Organization
Organization Name:OLYMPUS PAIN AND ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALONZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-998-2400
Mailing Address - Street 1:1001 12TH AVE STE 154
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3929
Mailing Address - Country:US
Mailing Address - Phone:469-998-2400
Mailing Address - Fax:469-998-2401
Practice Address - Street 1:1001 12TH AVE STE 154
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3929
Practice Address - Country:US
Practice Address - Phone:469-998-2400
Practice Address - Fax:469-998-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8858207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty