Provider Demographics
| NPI: | 1821157579 |
|---|---|
| Name: | AUSTIN REGIONAL CLINIC, PA |
| Entity Type: | Organization |
| Organization Name: | AUSTIN REGIONAL CLINIC, PA |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO/PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | ANAS |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | DAGHESTANI |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 512-231-5500 |
| Mailing Address - Street 1: | 6210 E US HWY 290 |
| Mailing Address - Street 2: | SUITE 420 - CREDENTIALING |
| Mailing Address - City: | AUSTIN |
| Mailing Address - State: | TX |
| Mailing Address - Zip Code: | 78723-1098 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 512-231-5516 |
| Mailing Address - Fax: | 512-406-6216 |
| Practice Address - Street 1: | 6210 E US HWY 290 |
| Practice Address - Street 2: | SUITE 420 - CREDENTIALING |
| Practice Address - City: | AUSTIN |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 78723-1098 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 512-231-5516 |
| Practice Address - Fax: | 512-406-6216 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-12-08 |
| Last Update Date: | 2019-02-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 207ZP0101X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TX | 133394009 | Medicaid | |
| TX | 133394003 | Medicaid | |
| TX | 210530601 | Medicaid | |
| TX | 133394007 | Medicaid | |
| TX | 133394007 | Medicaid | |
| TX | 00MT03 | Medicare PIN | |
| TX | 133394009 | Medicaid | |
| TX | 00224K | Medicare PIN |
