1558307660 NPI number — DR. THOMAS ROBERT AUSTGEN MD

Table of content: DR. THOMAS ROBERT AUSTGEN MD (NPI 1558307660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558307660 NPI number — DR. THOMAS ROBERT AUSTGEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUSTGEN
Provider First Name:
THOMAS
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AUSTGEN
Provider Other First Name:
THOMAS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1558307660
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11945 SAN JOSE BLVD
Provider Second Line Business Mailing Address:
BLDG 300
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223-1613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-396-1725
Provider Business Mailing Address Fax Number:
904-399-1717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1370 13TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
JACKSONVILLE BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32250-3206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-247-3858
Provider Business Practice Location Address Fax Number:
904-247-7079
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  ME95091 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00722976 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2922220 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 48980 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 294577 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4516825 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 270661000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 289542326A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 270661000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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