Provider Demographics
NPI:1356329569
Name:THE AUSTIN DIAGNOSTIC CLINIC, PLLC
Entity Type:Organization
Organization Name:THE AUSTIN DIAGNOSTIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:REBOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-5004
Mailing Address - Street 1:2000 HEALTH PARK DR DEPT OF
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-372-5004
Mailing Address - Fax:866-831-4898
Practice Address - Street 1:2400 CEDAR BEND DR
Practice Address - Street 2:DEPT OF FAMILY PRACTICE
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758
Practice Address - Country:US
Practice Address - Phone:512-901-4026
Practice Address - Fax:512-901-3926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140347906Medicaid
TX140347953Medicaid
TXCP9039Medicare PIN
TX140347906Medicaid
TX00A55WMedicare PIN