Healthcare Provider Details

I. General information

NPI: 1235535121
Provider Name (Legal Business Name): SPECIALTY CLINIC MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 EIGER RD STE 215
AUSTIN TX
78735-8977
US

IV. Provider business mailing address

4515 SETON CENTER PKWY STE 175
AUSTIN TX
78759-5290
US

V. Phone/Fax

Practice location:
  • Phone: 512-382-1933
  • Fax: 512-777-4949
Mailing address:
  • Phone: 512-382-1933
  • Fax: 512-777-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. JACQUELINE CAPISTRAN
Title or Position: BILLING MANAGER
Credential:
Phone: 512-382-1933