Provider Demographics
NPI:1265501076
Name:STEPHEN F. AUSTIN STATE UNIV. HEALTH SERVICE
Entity Type:Organization
Organization Name:STEPHEN F. AUSTIN STATE UNIV. HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-468-4008
Mailing Address - Street 1:2106 RAGUET ST N
Mailing Address - Street 2:BOX 13058
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75962-0001
Mailing Address - Country:US
Mailing Address - Phone:936-468-4008
Mailing Address - Fax:936-468-1316
Practice Address - Street 1:2106 RAGUET ST N
Practice Address - Street 2:BOX 13058
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75962-0001
Practice Address - Country:US
Practice Address - Phone:936-468-4008
Practice Address - Fax:936-468-1316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health