Provider Demographics
NPI:1629409909
Name:SPECIALTY CLINIC MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:SPECIALTY CLINIC MEDICAL GROUP, PLLC
Other - Org Name:SPECIALTY CLINIC OF AUSTIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIVYANSU
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-382-1933
Mailing Address - Street 1:2217 PARK BEND DR STE 300
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5674
Mailing Address - Country:US
Mailing Address - Phone:512-382-1933
Mailing Address - Fax:512-777-4949
Practice Address - Street 1:2217 PARK BEND DR STE 300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5674
Practice Address - Country:US
Practice Address - Phone:512-382-1933
Practice Address - Fax:512-777-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084P0800X
2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty