Provider Demographics
NPI:1669447926
Name:THE AUSTIN DIAGNOSTIC CLINIC, PLLC
Entity Type:Organization
Organization Name:THE AUSTIN DIAGNOSTIC CLINIC, PLLC
Other - Org Name:AUSTIN DIAGNOSTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:REBOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-5004
Mailing Address - Street 1:2000 HEALTH PARK DR DEPT OF
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-372-5004
Mailing Address - Fax:866-831-4898
Practice Address - Street 1:12221 MOPAC EXPRESSWAY NORTH
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758
Practice Address - Country:US
Practice Address - Phone:512-901-4019
Practice Address - Fax:512-901-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143047901Medicaid
TX0807840001Medicare NSC
TX143047901Medicaid
TXCP9039Medicare PIN