1316016710 NPI number — BRYKERWOOD SKIN AND VEIN CENTER PA

Table of content: (NPI 1316016710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316016710 NPI number — BRYKERWOOD SKIN AND VEIN CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRYKERWOOD SKIN AND VEIN CENTER 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:
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:
1316016710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 W 38TH STREET
Provider Second Line Business Mailing Address:
SUITE 315
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-302-4047
Provider Business Mailing Address Fax Number:
512-302-1629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W 38TH STREET
Provider Second Line Business Practice Location Address:
SUITE 315
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:
512-302-4047
Provider Business Practice Location Address Fax Number:
512-302-1629
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DANO
Authorized Official First Name:
JACULEEN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
DERMATOLOGIST
Authorized Official Telephone Number:
512-302-4047

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  TXJ4761 , 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: 0051DR . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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