Provider Demographics
NPI:1912183641
Name:NEUROLOGY AND ELECTROMYOGRAPHY CLINIC
Entity Type:Organization
Organization Name:NEUROLOGY AND ELECTROMYOGRAPHY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-674-9002
Mailing Address - Street 1:4201 MARATHON BLVD
Mailing Address - Street 2:STE 304
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3410
Mailing Address - Country:US
Mailing Address - Phone:512-371-1200
Mailing Address - Fax:
Practice Address - Street 1:4201 MARATHON BLVD
Practice Address - Street 2:STE 304
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3436
Practice Address - Country:US
Practice Address - Phone:512-371-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL21122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155764701Medicaid
TX00579TOtherBCBS
TX00579TMedicare PIN