Healthcare Provider Details

I. General information

NPI: 1699761494
Provider Name (Legal Business Name): AUSTIN SOUTHWEST ORTHOPAEDIC GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 05/17/2024
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 DAVIS LANE SUITE B200
AUSTIN TX
78749
US

IV. Provider business mailing address

7951 SHOAL CREEK BLVD STE 300
AUSTIN TX
78757-7582
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-1969
  • Fax: 512-458-2327
Mailing address:
  • Phone: 512-584-8404
  • Fax: 512-458-2327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRIAN L SULLIVAN
Title or Position: MD
Credential:
Phone: 512-451-1969