Basic Information
| Provider Information | |||||||||
| NPI: | 1962705434 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SETON ENT | ||||||||
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| OtherOrganizationName: | CHILDRENS EAR NOSE & THROAT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3705 MEDICAL PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124520231 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601B LEAH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786667849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124520231 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2010 | ||||||||
| LastUpdateDate: | 02/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | HARVEY | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5123248617 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 207YP0228X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 280494406 | 05 | TX | MEDICAID | 284094404 | 05 | TX | MEDICAID | 284094405 | 05 | TX | MEDICAID | 284094402 | 05 | TX | MEDICAID | 284094401 | 05 | TX | MEDICAID | 284094403 | 05 | TX | MEDICAID |