Healthcare Provider Details

I. General information

NPI: 1629409909
Provider Name (Legal Business Name): SPECIALTY CLINIC MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 PARK BEND DR STE 300
AUSTIN TX
78758-5674
US

IV. Provider business mailing address

2217 PARK BEND DR STE 300
AUSTIN TX
78758-5674
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 TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DIVYANSU PATEL
Title or Position: MANAGER
Credential: M.D.
Phone: 512-382-1933