1124505920 NPI number — AUSTIN REGIONAL CLINIC, PA

Table of content: (NPI 1124505920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124505920 NPI number — AUSTIN REGIONAL CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUSTIN REGIONAL CLINIC, PA
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:
1124505920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6210 E US HWY 290
Provider Second Line Business Mailing Address:
SUITE 420 - CREDENTIALING
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78723-1098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-336-3802
Provider Business Mailing Address Fax Number:
512-406-6216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 E WHITESTONE BLVD
Provider Second Line Business Practice Location Address:
BLDG B
Provider Business Practice Location Address City Name:
CEDAR PARK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78613-9040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-259-3467
Provider Business Practice Location Address Fax Number:
512-406-7303
Provider Enumeration Date:
07/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DAGHESTANI
Authorized Official First Name:
ANAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
512-231-5500

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1333940-07 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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