Basic Information
| Provider Information | |||||||||
| NPI: | 1619071362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUSTIN BONE & JOINT CLINIC A PROF A ASSOC | ||||||||
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| OtherOrganizationName: | AUSTIN BONE AND JOINT CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 E 32ND ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787052700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124776341 | ||||||||
| FaxNumber: | 5124771148 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 E 32ND ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787052700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124776341 | ||||||||
| FaxNumber: | 5124771148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | PEARCE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ORTHOPEADIC SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 5124776341 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 081856901 | 05 | TX | MEDICAID |