Provider Demographics
NPI:1588638548
Name:AUSTIN DIAGNOSTIC CLINIC, PA
Entity Type:Organization
Organization Name:AUSTIN DIAGNOSTIC CLINIC, PA
Other - Org Name:AUSTIN DIAGNOSTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-901-4937
Mailing Address - Street 1:12221 MOPAC EXPRESSWAY N
Mailing Address - Street 2:DEPT OF ORTHOPAEDIC SURGERY
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2483
Mailing Address - Country:US
Mailing Address - Phone:512-901-4015
Mailing Address - Fax:512-901-3915
Practice Address - Street 1:12221 MOPAC EXPRESSWAY N
Practice Address - Street 2:DEPT OF ORTHOPAEDIC SURGERY
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2483
Practice Address - Country:US
Practice Address - Phone:512-901-4015
Practice Address - Fax:512-901-3915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140347911Medicaid
TX140347950Medicaid
TX0807840001Medicare NSC
TX140347950Medicaid
TX140347911Medicaid