Healthcare Provider Details

I. General information

NPI: 1699190876
Provider Name (Legal Business Name): NEUROLOGY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 17TH ST
AUSTIN TX
78701-1103
US

IV. Provider business mailing address

601 W 17TH ST
AUSTIN TX
78701-1103
US

V. Phone/Fax

Practice location:
  • Phone: 512-708-9200
  • Fax: 512-532-6261
Mailing address:
  • Phone: 512-708-9200
  • Fax: 512-532-6261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA M VERELLEN
Title or Position: PRESIDENT
Credential: MD
Phone: 512-458-2600