Basic Information
Provider Information
NPI: 1164756342
EntityType: 2
ReplacementNPI:  
OrganizationName: TRI-COUNTY PRACTICE ASSOCIATION
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SETON SPINE AND SCOLIOSIS CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1400 N IH 35
Address2: SUITE 300
City: AUSTIN
State: TX
PostalCode: 787011926
CountryCode: US
TelephoneNumber: 5123243580
FaxNumber:  
Practice Location
Address1: 6001 KYLE PKWY
Address2:  
City: KYLE
State: TX
PostalCode: 786406112
CountryCode: US
TelephoneNumber: 5123243580
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/22/2009
LastUpdateDate: 09/22/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LEE
AuthorizedOfficialFirstName: MARK
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: MEDICAL DIRECTOR
AuthorizedOfficialTelephone: 5123240910
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: ASCENSION HEALTH
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
204C00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine 

No ID Information.


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