Basic Information
| Provider Information | |||||||||
| NPI: | 1578690798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUSTIN TRAVIS COUNTY MHMR CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3548 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787643548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124457787 | ||||||||
| FaxNumber: | 5124404059 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 E 2ND ST STE D | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787024491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128043600 | ||||||||
| FaxNumber: | 5124761469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VAN NORMAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | RUSSEL | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5124404021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | X | Agencies | Case Management | 251S00000X | X | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00P336 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |