Basic Information
| Provider Information | |||||||||
| NPI: | 1043443591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEARING CENTERS OF AUSTIN EAR NOSE & THROAT CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3705 MEDICAL PKWY STE 320 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124540392 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3705 MEDICAL PKWY STE 320 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124540392 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2009 | ||||||||
| LastUpdateDate: | 06/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5124540392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | N | Suppliers | Hearing Aid Equipment | 237600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 210286502 | 01 | TX | MEDICAID CSHCN | OTHER | 210286501 | 05 | TX | MEDICAID |