1255639613 NPI number — ATLANTIS MEDICAL CLINIC - AUSTIN, P.A.

Table of content: (NPI 1255639613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255639613 NPI number — ATLANTIS MEDICAL CLINIC - AUSTIN, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTIS MEDICAL CLINIC - AUSTIN, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDICAL-DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255639613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2515 MCKINNEY AVE
Provider Second Line Business Mailing Address:
SUITE 940
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75201-1908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-478-9117
Provider Business Mailing Address Fax Number:
817-887-2305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2015 E RIVERSIDE DR
Provider Second Line Business Practice Location Address:
BLDG 2, UNIT D
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78741-1324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-652-0044
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ADDISON
Authorized Official First Name:
CANDICE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
512-652-0044

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  N7984 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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