Provider Demographics
NPI:1821229568
Name:ST. DAVID'S SPECIALIZED WOMEN'S SERVICES, PLLC
Entity Type:Organization
Organization Name:ST. DAVID'S SPECIALIZED WOMEN'S SERVICES, PLLC
Other - Org Name:NORTH AUSTIN MATERNAL FETAL MEDICINE, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:REBOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-708-9700
Mailing Address - Street 1:98 SAN JACINTO BLVD
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-4082
Mailing Address - Country:US
Mailing Address - Phone:512-708-9700
Mailing Address - Fax:512-482-4191
Practice Address - Street 1:12200 RENFERT WAY
Practice Address - Street 2:SUITE G-3
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5614
Practice Address - Country:US
Practice Address - Phone:512-821-2540
Practice Address - Fax:512-973-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2079170-01Medicaid
TX2079170-01Medicaid