Healthcare Provider Details

I. General information

NPI: 1215204540
Provider Name (Legal Business Name): PREMIER GYNECOLOGY OF AUSTIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W 9TH ST
AUSTIN TX
78703-4924
US

IV. Provider business mailing address

1010 W 9TH ST
AUSTIN TX
78703-4924
US

V. Phone/Fax

Practice location:
  • Phone: 512-459-4405
  • Fax:
Mailing address:
  • Phone: 512-459-4405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCREVEN EDGERTON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 512-459-4405