Provider Demographics
NPI:1790739472
Name:SPACE CITY PAIN SPECIALISTS
Entity Type:Organization
Organization Name:SPACE CITY PAIN SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-338-4443
Mailing Address - Street 1:17448 HIGHWAY 3
Mailing Address - Street 2:SUITE 136
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4197
Mailing Address - Country:US
Mailing Address - Phone:281-338-4443
Mailing Address - Fax:281-338-8821
Practice Address - Street 1:17448 HIGHWAY 3
Practice Address - Street 2:SUITE 136
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4197
Practice Address - Country:US
Practice Address - Phone:281-338-4443
Practice Address - Fax:281-338-8821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0021LWOtherBC/BS OF TEXAS
TX0021LWOtherBC/BS OF TEXAS
TX00338XMedicare ID - Type Unspecified