Basic Information
| Provider Information | |||||||||
| NPI: | 1205144029 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ART MEDICAL ALLIANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 203968 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787203968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124671100 | ||||||||
| FaxNumber: | 5124671101 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 W ANDERSON LN | ||||||||
| Address2: | STE 103 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787571501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124671100 | ||||||||
| FaxNumber: | 5124671101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2010 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | SEGURA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5124671100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | TXB126057 | 01 | TX | MEDICARE PTAN | OTHER |