Provider Demographics
NPI:1639177876
Name:AUSTIN SURGICAL CLINIC
Entity Type:Organization
Organization Name:AUSTIN SURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-478-3402
Mailing Address - Street 1:2911 MEDICAL ARTS ST
Mailing Address - Street 2:BLDG 2
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-3376
Mailing Address - Country:US
Mailing Address - Phone:512-478-3402
Mailing Address - Fax:512-478-7114
Practice Address - Street 1:2911 MEDICAL ARTS ST
Practice Address - Street 2:BLDG 2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-3376
Practice Address - Country:US
Practice Address - Phone:512-478-3402
Practice Address - Fax:512-478-7114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0080041803208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R597Medicare ID - Type Unspecified