1821229568 NPI number — ST. DAVID'S SPECIALIZED WOMEN'S SERVICES, PLLC

Table of content: (NPI 1821229568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821229568 NPI number — ST. DAVID'S SPECIALIZED WOMEN'S SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. DAVID'S SPECIALIZED WOMEN'S SERVICES, PLLC
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:
6
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:
1821229568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
98 SAN JACINTO BLVD
Provider Second Line Business Mailing Address:
SUITE 1800
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78701-4082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-708-9700
Provider Business Mailing Address Fax Number:
512-482-4191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12200 RENFERT WAY
Provider Second Line Business Practice Location Address:
SUITE G-3
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78758-5614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-821-2540
Provider Business Practice Location Address Fax Number:
512-973-3533
Provider Enumeration Date:
07/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
REBOK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
512-708-9700

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2079170-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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