Basic Information
| Provider Information | |||||||||
| NPI: | 1588638548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUSTIN DIAGNOSTIC CLINIC, PA | ||||||||
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| OtherOrganizationName: | AUSTIN DIAGNOSTIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 MOPAC EXPRESSWAY N | ||||||||
| Address2: | DEPT OF ORTHOPAEDIC SURGERY | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014015 | ||||||||
| FaxNumber: | 5129013915 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 MOPAC EXPRESSWAY N | ||||||||
| Address2: | DEPT OF ORTHOPAEDIC SURGERY | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014015 | ||||||||
| FaxNumber: | 5129013915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 11/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | ANDREW | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5129014937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 140347911 | 05 | TX | MEDICAID | 140347950 | 05 | TX | MEDICAID |