Provider Demographics
NPI:1245417294
Name:AUSTIN DERMCARE MSO, LLC
Entity Type:Organization
Organization Name:AUSTIN DERMCARE MSO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-476-9195
Mailing Address - Street 1:3807 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:STE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8965
Mailing Address - Country:US
Mailing Address - Phone:512-476-9195
Mailing Address - Fax:512-476-2857
Practice Address - Street 1:3807 SPICEWOOD SPRINGS RD
Practice Address - Street 2:STE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8965
Practice Address - Country:US
Practice Address - Phone:512-476-9195
Practice Address - Fax:512-476-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0021HWOtherBCBS GROUP BILLING ID
TXCK3641OtherRR MEDICARE GRP NUMBER
TXCK3641OtherRR MEDICARE GRP NUMBER