Provider Demographics
NPI:1013905900
Name:PAIN MANAGEMENT ASSOCIATES OF EAST TEXAS, PA
Entity Type:Organization
Organization Name:PAIN MANAGEMENT ASSOCIATES OF EAST TEXAS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-675-1186
Mailing Address - Street 1:PO BOX 2427
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-2427
Mailing Address - Country:US
Mailing Address - Phone:903-723-2465
Mailing Address - Fax:903-677-1694
Practice Address - Street 1:300 WILLOW CREEK PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4421
Practice Address - Country:US
Practice Address - Phone:903-723-2465
Practice Address - Fax:903-677-1694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1709560-01Medicaid
DC5302Medicare PIN
TX1709560-01Medicaid