Healthcare Provider Details

I. General information

NPI: 1790318566
Provider Name (Legal Business Name): VMD PRIMARY PROVIDERS OF SOUTH CENTRAL TEXAS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W 34TH ST
AUSTIN TX
78705-1205
US

IV. Provider business mailing address

PO BOX 360340
PITTSBURGH PA
15251-6340
US

V. Phone/Fax

Practice location:
  • Phone: 512-988-5355
  • Fax: 512-323-0307
Mailing address:
  • Phone: 512-988-5355
  • Fax: 512-323-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA RAGER
Title or Position: DIRECTOR REVENUE CYCLE
Credential:
Phone: 844-969-0686