Provider Demographics
NPI:1407218985
Name:AUSTIN REGIONAL CLINIC, PA
Entity Type:Organization
Organization Name:AUSTIN REGIONAL CLINIC, PA
Other - Org Name:ARC - ANDERSON MILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGHESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-231-5500
Mailing Address - Street 1:6210 E US HWY 290
Mailing Address - Street 2:SUITE 420 - CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1098
Mailing Address - Country:US
Mailing Address - Phone:512-338-3802
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:10401 ANDERSON MILL RD
Practice Address - Street 2:SUITE 110B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-2579
Practice Address - Country:US
Practice Address - Phone:512-250-5571
Practice Address - Fax:512-406-7300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1535332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1333940-03Medicaid
TX00MT03Medicare PIN