Provider Demographics
NPI:1932210838
Name:PROVIDENCE HEALTH ALLIANCE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/COO
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-324-5846
Mailing Address - Street 1:1345 PHILOMENA ST
Mailing Address - Street 2:SUITE 410.3
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723
Mailing Address - Country:US
Mailing Address - Phone:800-566-5050
Mailing Address - Fax:254-537-6869
Practice Address - Street 1:6901 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7910
Practice Address - Country:US
Practice Address - Phone:254-751-4061
Practice Address - Fax:254-537-6869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084249401Medicaid
TX092245202Medicaid
TX00N59XOtherBCBS OF TEXAS
TX092245202Medicaid