Provider Demographics
NPI:1619055365
Name:AUSTIN GASTROENTEROLOGY PA
Entity Type:Organization
Organization Name:AUSTIN GASTROENTEROLOGY PA
Other - Org Name:AUSTIN GASTROENTEROLOGY LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, JD
Authorized Official - Phone:512-485-5879
Mailing Address - Street 1:8015 SHOAL CREEK BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-8051
Mailing Address - Country:US
Mailing Address - Phone:512-420-0186
Mailing Address - Fax:512-420-0397
Practice Address - Street 1:8015 SHOAL CREEK BLVD STE 116
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-8051
Practice Address - Country:US
Practice Address - Phone:512-420-0186
Practice Address - Fax:512-420-0397
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUSTIN GASTROENTEROLOGY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D1056054291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D1056054OtherCMS CLIA
TX45D1056054OtherCMS CLIA