Provider Demographics
NPI:1013914993
Name:SOUTH AUSTIN OB-GYN
Entity Type:Organization
Organization Name:SOUTH AUSTIN OB-GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SUPNET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-373-4000
Mailing Address - Street 1:4101 JAMES CASEY ST
Mailing Address - Street 2:STE 330
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1145
Mailing Address - Country:US
Mailing Address - Phone:512-373-4000
Mailing Address - Fax:512-373-4010
Practice Address - Street 1:4101 JAMES CASEY ST
Practice Address - Street 2:STE 330
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1145
Practice Address - Country:US
Practice Address - Phone:512-373-4000
Practice Address - Fax:512-373-4010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3152207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00238VMedicare ID - Type Unspecified