Provider Demographics
NPI:1982888749
Name:CITY OF AUSTIN
Entity Type:Organization
Organization Name:CITY OF AUSTIN
Other - Org Name:CITY OF AUSTIN/ATCCHC-FQHC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:VLIET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-972-4242
Mailing Address - Street 1:211 COMAL ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4326
Mailing Address - Country:US
Mailing Address - Phone:512-972-4322
Mailing Address - Fax:512-972-4220
Practice Address - Street 1:15 WALLER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-5240
Practice Address - Country:US
Practice Address - Phone:512-972-4074
Practice Address - Fax:512-972-4088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF AUSTIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00HE66OtherMEDICARE PART B GROUP #