1245439819 NPI number — SPORTS & SPINE ASSOCIATES, P.A.

Table of content: (NPI 1245439819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245439819 NPI number — SPORTS & SPINE ASSOCIATES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS & SPINE ASSOCIATES, 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:
Provider Other Organization Name Type Code:
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:
1245439819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27165
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:
78755-2165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-358-0500
Provider Business Mailing Address Fax Number:
512-358-0520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7756 NORTHCROSS DR
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78757-1735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-358-0500
Provider Business Practice Location Address Fax Number:
512-358-0520
Provider Enumeration Date:
07/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WASSERBURGER
Authorized Official First Name:
LORI
Authorized Official Middle Name:
BETH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-358-0500

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  H2890 , 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: 4295756 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: E98496 . This is a "UPIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1033217450 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 80W550 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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