1033166368 NPI number — DR. MICHAEL MUSGROVE MD

Table of content: DR. MICHAEL MUSGROVE MD (NPI 1033166368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033166368 NPI number — DR. MICHAEL MUSGROVE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUSGROVE
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1033166368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 SAM BASS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78681-4137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-964-6992
Provider Business Mailing Address Fax Number:
512-388-0373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 SAM BASS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78681-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-964-6992
Provider Business Practice Location Address Fax Number:
512-388-0373
Provider Enumeration Date:
05/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  M3334 , 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)

  • Identifier: 1862104-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".