Basic Information
| Provider Information | |||||||||
| NPI: | 1407084858 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUSTIN NEUROSURGICAL AND SPINE INSTITUTE, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3724 EXECUTIVE CENTER DR STE G10 | ||||||||
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| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787311665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123765247 | ||||||||
| FaxNumber: | 5123766252 | ||||||||
| Practice Location | |||||||||
| Address1: | 1009 W SAN ANTONIO ST | ||||||||
| Address2: | |||||||||
| City: | LOCKHART | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786442421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123455925 | ||||||||
| FaxNumber: | 5123437113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5123765247 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 085111501 | 05 | TX | MEDICAID |