1225199557 NPI number — PM MANAGEMENT-AUSTIN NC LLC

Table of content: (NPI 1225199557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225199557 NPI number — PM MANAGEMENT-AUSTIN NC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PM MANAGEMENT-AUSTIN NC LLC
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:
1225199557
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1703 W 5TH ST
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78703-4893
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-344-4235
Provider Business Mailing Address Fax Number:
877-639-9530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12021 METRIC BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78758-8616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-228-3300
Provider Business Practice Location Address Fax Number:
512-228-3349
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANSON
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
512-344-4235

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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: 005261 . This is a "FACILITY ID NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001003645 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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