Basic Information
| Provider Information | |||||||||
| NPI: | 1700887700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST DAVIDS HEART & VASCULAR, PLLC | ||||||||
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| OtherOrganizationName: | AUSTIN HEART, PLLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7800 SHOAL CREEK BLVD | ||||||||
| Address2: | SUITE 205N | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122064341 | ||||||||
| FaxNumber: | 5124071947 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 N LAMAR BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787564080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122063600 | ||||||||
| FaxNumber: | 5124542581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | GORNIK | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5122064367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AUSTIN HEART PLLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0937849-03 | 05 | TX | MEDICAID | 0949521-02 | 05 | TX | MEDICAID |