Healthcare Provider Details

I. General information

NPI: 1063956332
Provider Name (Legal Business Name): NORTHSIDE NEURODIAGNOSTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7421 BURNET RD # 145
AUSTIN TX
78757-2244
US

IV. Provider business mailing address

7421 BURNET RD # 145
AUSTIN TX
78757-2244
US

V. Phone/Fax

Practice location:
  • Phone: 512-538-2175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HARI TUMU
Title or Position: PRESIDENT
Credential:
Phone: 512-538-2175