Provider Demographics
NPI:1598708216
Name:CENTRAL TEXAS DIAGNOSTIC CLINIC
Entity Type:Organization
Organization Name:CENTRAL TEXAS DIAGNOSTIC CLINIC
Other - Org Name:ROUND ROCK INTERNAL MED. ASSOC.
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KINNIBRUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-244-3775
Mailing Address - Street 1:7200 WYOMING SPRINGS DR.
Mailing Address - Street 2:STE. 1600
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681
Mailing Address - Country:US
Mailing Address - Phone:512-244-3554
Mailing Address - Fax:512-244-2942
Practice Address - Street 1:7200 WYOMING SPRINGS DR.
Practice Address - Street 2:STE. 1600
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681
Practice Address - Country:US
Practice Address - Phone:512-244-3554
Practice Address - Fax:512-244-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty