Provider Demographics
NPI:1619923950
Name:AUSTIN DIAGNOSTIC CLINIC, PA
Entity Type:Organization
Organization Name:AUSTIN DIAGNOSTIC CLINIC, PA
Other - Org Name:
Other - Org Type:
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 MO PAC EXPWY N
Mailing Address - Street 2:AMBULATORY SURGERY CENTER
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2483
Mailing Address - Country:US
Mailing Address - Phone:512-901-4029
Mailing Address - Fax:512-901-3920
Practice Address - Street 1:7600 N CAPITAL OF TEXAS HWY
Practice Address - Street 2:AMBULATORY SURGERY CENTER
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1181
Practice Address - Country:US
Practice Address - Phone:512-901-4029
Practice Address - Fax:512-901-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008167261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140347948Medicaid
TX0807840001Medicare NSC
TXCP9039Medicare PIN
TX140347948Medicaid