Healthcare Provider Details

I. General information

NPI: 1013981182
Provider Name (Legal Business Name): AUSTIN DIAGNOSTIC CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12221 MO PAC EXPWY NORTH DEPT OF PHYSICAL THERAPY
AUSTIN TX
78758-2483
US

IV. Provider business mailing address

12221 MO PAC EXPWY NORTH DEPT OF PHYSICAL THERAPY
AUSTIN TX
78758-2483
US

V. Phone/Fax

Practice location:
  • Phone: 512-901-4402
  • Fax: 512-901-4103
Mailing address:
  • Phone: 512-901-4402
  • Fax: 512-901-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ELLEN M ANDREW
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 512-901-4937