Basic Information
| Provider Information | |||||||||
| NPI: | 1205837994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYNES | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | SHELBY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10202 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787661202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172849850 | ||||||||
| FaxNumber: | 8172843425 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 ROUND ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123411000 | ||||||||
| FaxNumber: | 5126718548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | G8999 | TX | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1101263-02 | 05 | TX | MEDICAID | 74-2423759 | 01 | TAX ID | OTHER |