Basic Information
| Provider Information | |||||||||
| NPI: | 1821079559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TATUM | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 W 38TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051006 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 RED RIVER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | 036160360 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207QH0002X | 2022022258 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207QH0002X | R9296 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 807026 | 05 | AZ | MEDICAID |