Basic Information
| Provider Information | |||||||||
| NPI: | 1326061714 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARDIOTHORACIC AND VASCULAR SURGEONS,PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VEINSOLUTIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 W 40TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787564010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124598753 | ||||||||
| FaxNumber: | 5126518441 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 W 40TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787564010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124598753 | ||||||||
| FaxNumber: | 5126518441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5124598753 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDIOTHORACIC AND VASCULAR SURGEONS, PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1326061714 | 01 | TX | NPI | OTHER | 0025DM | 01 | TX | SAN ANGELO BCBS GROUP NO | OTHER | 00R517 | 01 | TX | BCBS AUSTIN GROUP NO | OTHER | 121680602 | 05 | TX | MEDICAID |