1215258918 NPI number — AUSTIN SOUTHWEST ORTHOPAEDIC GROUP, P.A.

Table of content: (NPI 1942385430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215258918 NPI number — AUSTIN SOUTHWEST ORTHOPAEDIC GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUSTIN SOUTHWEST ORTHOPAEDIC GROUP, 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:
SOUTHWEST ORTHOPAEDIC GROUP
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:
1215258918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 W WILLIAM CANNON DR
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78745-5257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-451-1969
Provider Business Mailing Address Fax Number:
512-458-2327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 HWY 71 W
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
BASTROP
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78602-3931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-451-1969
Provider Business Practice Location Address Fax Number:
512-458-2327
Provider Enumeration Date:
06/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
512-451-1969

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  K7496 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0106X , with the licence number: K9864 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: K7496 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2103178-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com