Provider Demographics
NPI:1972731495
Name:BALCONES HEALTHCARE ASSOCIATES, PA
Entity Type:Organization
Organization Name:BALCONES HEALTHCARE ASSOCIATES, PA
Other - Org Name:HIGHLAND LAKES PAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURGEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-868-4352
Mailing Address - Street 1:PO BOX 268969
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8969
Mailing Address - Country:US
Mailing Address - Phone:512-868-4352
Mailing Address - Fax:512-868-4354
Practice Address - Street 1:200 COUNTY ROAD 340A
Practice Address - Street 2:BUILDING 1, SUITE 4
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611-4537
Practice Address - Country:US
Practice Address - Phone:512-868-4352
Practice Address - Fax:512-868-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9637208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2128704-01Medicaid
TXTXB114811Medicare PIN