Basic Information
Provider Information | |||||||||
NPI: | 1508338286 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATCARE GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3711 S MOPAC EXPY | ||||||||
Address2: | BLDG 2 STE 400 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 78746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5122715844 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 14090 HG TRUEMAN RD # 1300 | ||||||||
Address2: |   | ||||||||
City: | SOLOMONS | ||||||||
State: | MD | ||||||||
PostalCode: | 206883151 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103942800 | ||||||||
FaxNumber: | 4104523088 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2018 | ||||||||
LastUpdateDate: | 12/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURGER | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: | THEODORE | ||||||||
AuthorizedOfficialTitleorPosition: | CMO | ||||||||
AuthorizedOfficialTelephone: | 4102960018 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.