Healthcare Provider Details

I. General information

NPI: 1972011658
Provider Name (Legal Business Name): AUSTIN DIAGNOSTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12221 N MOPAC EXPY
AUSTIN TX
78758-2401
US

IV. Provider business mailing address

12221 N MOPAC EXPY
AUSTIN TX
78758-2401
US

V. Phone/Fax

Practice location:
  • Phone: 512-901-4009
  • Fax: 512-901-3909
Mailing address:
  • Phone: 512-901-4937
  • Fax: 512-901-3945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA SHANNON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 512-901-4937