1134372030 NPI number — CEDAR PARK ONCOLOGY CLINIC

Table of content: (NPI 1134372030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134372030 NPI number — CEDAR PARK ONCOLOGY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR PARK ONCOLOGY CLINIC
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:
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:
1134372030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2207 S CLEAR CREEK RD
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76549-4132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-526-5353
Provider Business Mailing Address Fax Number:
254-554-5298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
921 W NEW HOPE DR
Provider Second Line Business Practice Location Address:
SUITE 702
Provider Business Practice Location Address City Name:
CEDAR PARK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78613-6778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-986-4036
Provider Business Practice Location Address Fax Number:
512-986-4596
Provider Enumeration Date:
10/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SUBRAMANIAN
Authorized Official First Name:
MANI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
254-526-5353

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  G4724 , 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: 8S4240 . This is a "BCBS TX PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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