Healthcare Provider Details

I. General information

NPI: 1508080516
Provider Name (Legal Business Name): AUSTIN CHILDREN'S CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11673 JOLLYVILLE RD SUITE 104
AUSTIN TX
78759-3933
US

IV. Provider business mailing address

11673 JOLLYVILLE RD SUITE 104
AUSTIN TX
78759-3933
US

V. Phone/Fax

Practice location:
  • Phone: 512-338-5130
  • Fax: 512-338-5112
Mailing address:
  • Phone: 512-338-5130
  • Fax: 512-338-5112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA PAULINE MYERS
Title or Position: OFFICE MANAGER
Credential:
Phone: 512-338-5130