1255395810 NPI number — HURT, JACKNOW, MOORE, CONNOR, WELLS, MICHELS, YURCO, LISTROM & HUANG

Table of content: (NPI 1255395810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255395810 NPI number — HURT, JACKNOW, MOORE, CONNOR, WELLS, MICHELS, YURCO, LISTROM & HUANG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HURT, JACKNOW, MOORE, CONNOR, WELLS, MICHELS, YURCO, LISTROM & HUANG
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:
CLINICAL PATHOLOGY ASSOCIATES
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:
1255395810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 28770
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-579-4000
Provider Business Mailing Address Fax Number:
512-439-2814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3445 EXECUTIVE CENTER DR
Provider Second Line Business Practice Location Address:
STE 250
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-579-4000
Provider Business Practice Location Address Fax Number:
512-439-2814
Provider Enumeration Date:
04/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAAS
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-579-4000

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 00RM54 , 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: 112538701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112138700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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