Basic Information
| Provider Information | |||||||||
| NPI: | 1013981182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUSTIN DIAGNOSTIC CLINIC, PA | ||||||||
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| OtherOrganizationName: | AUSTIN DIAGNOSTIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 MO PAC EXPWY NORTH | ||||||||
| Address2: | DEPT OF PHYSICAL THERAPY | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014402 | ||||||||
| FaxNumber: | 5129014103 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 MO PAC EXPWY NORTH | ||||||||
| Address2: | DEPT OF PHYSICAL THERAPY | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014402 | ||||||||
| FaxNumber: | 5129014103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | ANDREW | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5129014937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 140347946 | 05 | TX | MEDICAID |