Provider Demographics
NPI:1770223901
Name:PSA AMBULATORY SURGICAL CENTER OF SOUTH AUSTIN, LLC
Entity Type:Organization
Organization Name:PSA AMBULATORY SURGICAL CENTER OF SOUTH AUSTIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:LAURYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-877-1869
Mailing Address - Street 1:PO BOX 208373
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8373
Mailing Address - Country:US
Mailing Address - Phone:512-485-7208
Mailing Address - Fax:844-364-8678
Practice Address - Street 1:701 E FM 1626 STE 300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-2656
Practice Address - Country:US
Practice Address - Phone:855-876-7246
Practice Address - Fax:855-277-5070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-29
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130623OtherSTATE OF TEXAS