Provider Demographics
NPI:1891820106
Name:RONALD E. MANICOM, MD, PA
Entity Type:Organization
Organization Name:RONALD E. MANICOM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-248-9000
Mailing Address - Street 1:1200 LAKEWAY DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4474
Mailing Address - Country:US
Mailing Address - Phone:512-248-9000
Mailing Address - Fax:512-248-9012
Practice Address - Street 1:1200 LAKEWAY DR
Practice Address - Street 2:SUITE 8
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4474
Practice Address - Country:US
Practice Address - Phone:512-248-9000
Practice Address - Fax:512-248-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC9055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC18737Medicare UPIN
TX00392ZMedicare PIN