Provider Demographics
NPI:1073591202
Name:THE AUSTIN DIAGNOSTIC CLINIC, PLLC
Entity Type:Organization
Organization Name:THE AUSTIN DIAGNOSTIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:REBOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-5004
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-372-5004
Mailing Address - Fax:866-831-4898
Practice Address - Street 1:12221 N MO PAC EXPY
Practice Address - Street 2:DEPT OF INTERNAL MEDICINE
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758
Practice Address - Country:US
Practice Address - Phone:512-901-4009
Practice Address - Fax:512-901-3909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140347921Medicaid
TXCP9039Medicare PIN
TX0807840001Medicare NSC
TX00DG65Medicare PIN