Provider Demographics
NPI:1255639613
Name:ATLANTIS MEDICAL CLINIC - AUSTIN, P.A.
Entity type:Organization
Organization Name:ATLANTIS MEDICAL CLINIC - AUSTIN, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-652-0044
Mailing Address - Street 1:2515 MCKINNEY AVE
Mailing Address - Street 2:SUITE 940
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-1908
Mailing Address - Country:US
Mailing Address - Phone:682-478-9117
Mailing Address - Fax:817-887-2305
Practice Address - Street 1:2015 E RIVERSIDE DR
Practice Address - Street 2:BLDG 2, UNIT D
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-1324
Practice Address - Country:US
Practice Address - Phone:512-652-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty