Provider Demographics
NPI:1336304732
Name:LEGACY HEART CARE OF AUSTIN LLC
Entity Type:Organization
Organization Name:LEGACY HEART CARE OF AUSTIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-423-4400
Mailing Address - Street 1:2500 WEST FWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5848
Mailing Address - Country:US
Mailing Address - Phone:817-423-4400
Mailing Address - Fax:817-423-8080
Practice Address - Street 1:901 W 38TH ST
Practice Address - Street 2:SUITE 403
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1163
Practice Address - Country:US
Practice Address - Phone:817-423-4400
Practice Address - Fax:817-423-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX654915364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3115Medicare PIN