Provider Demographics
NPI:1609021765
Name:BLACKHAWK PHYSICIAN GROUP
Entity Type:Organization
Organization Name:BLACKHAWK PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:BIEDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-681-3440
Mailing Address - Street 1:6500 RIVER PLACE BLVD
Mailing Address - Street 2:BUILDING 1, SUITE 350
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-1119
Mailing Address - Country:US
Mailing Address - Phone:512-681-3440
Mailing Address - Fax:
Practice Address - Street 1:1700 BRAZOS AVE
Practice Address - Street 2:
Practice Address - City:ROCKDALE
Practice Address - State:TX
Practice Address - Zip Code:76567-2517
Practice Address - Country:US
Practice Address - Phone:512-446-4502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACKHAWK HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty