Provider Demographics
NPI:1003268202
Name:E. A. AUSTIN DO PC
Entity Type:Organization
Organization Name:E. A. AUSTIN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:CONQUEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-0340
Mailing Address - Street 1:110 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2340
Mailing Address - Country:US
Mailing Address - Phone:231-946-0911
Mailing Address - Fax:231-935-0343
Practice Address - Street 1:110 S MADISON ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2340
Practice Address - Country:US
Practice Address - Phone:231-946-0911
Practice Address - Fax:231-935-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010176422084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477715076Medicaid
MIC36078043Medicare PIN