Provider Demographics
NPI:1235535121
Name:SPECIALTY CLINIC MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:SPECIALTY CLINIC MEDICAL GROUP, PLLC
Other - Org Name:SPECIALTY CLINIC OF AUSTIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPISTRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-382-1933
Mailing Address - Street 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:STE 175
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:512-382-1933
Mailing Address - Fax:512-777-4949
Practice Address - Street 1:5625 EIGER RD
Practice Address - Street 2:STE 215
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8977
Practice Address - Country:US
Practice Address - Phone:512-382-1933
Practice Address - Fax:512-777-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty