Basic Information
| Provider Information | |||||||||
| NPI: | 1407839129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE AUSTIN DIAGNOSTIC CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR DEPT OF | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153725004 | ||||||||
| FaxNumber: | 8668314898 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 N MO PAC EXPWY | ||||||||
| Address2: | DEPT OF ALLERGY | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014002 | ||||||||
| FaxNumber: | 5129013902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | REBOK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153725004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 140347952 | 05 | TX | MEDICAID | 140347902 | 05 | TX | MEDICAID |