Provider Demographics
NPI:1013981182
Name:AUSTIN DIAGNOSTIC CLINIC, PA
Entity Type:Organization
Organization Name:AUSTIN DIAGNOSTIC CLINIC, PA
Other - Org Name:AUSTIN DIAGNOSTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-901-4937
Mailing Address - Street 1:12221 MO PAC EXPWY NORTH
Mailing Address - Street 2:DEPT OF PHYSICAL THERAPY
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2483
Mailing Address - Country:US
Mailing Address - Phone:512-901-4402
Mailing Address - Fax:512-901-4103
Practice Address - Street 1:12221 MO PAC EXPWY NORTH
Practice Address - Street 2:DEPT OF PHYSICAL THERAPY
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2483
Practice Address - Country:US
Practice Address - Phone:512-901-4402
Practice Address - Fax:512-901-4103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140347946Medicaid
TX00247XMedicare PIN
TX0807840001Medicare NSC
TXCP9039Medicare PIN