Provider Demographics
NPI:1083938765
Name:MEDICAL PARK TOWER SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MEDICAL PARK TOWER SURGERY CENTER, LLC
Other - Org Name:MEDICAL PARK TOWER SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-343-0832
Mailing Address - Street 1:1301 W 38TH ST
Mailing Address - Street 2:STE 109
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1010
Mailing Address - Country:US
Mailing Address - Phone:512-354-3000
Mailing Address - Fax:512-354-3009
Practice Address - Street 1:1301 W 38TH ST
Practice Address - Street 2:STE 109
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1000
Practice Address - Country:US
Practice Address - Phone:512-354-3000
Practice Address - Fax:512-354-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130050261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2945552Medicaid
TXP00928912OtherRAILROAD MEDICARE
TX2945552Medicaid
TXP00928912OtherRAILROAD MEDICARE