=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013914993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH AUSTIN OB-GYN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2005
-----------------------------------------------------
Last Update Date | 10/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4101 JAMES CASEY ST STE 330
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-373-4000
-----------------------------------------------------
Fax | 512-373-4010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4101 JAMES CASEY ST STE 330
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-373-4000
-----------------------------------------------------
Fax | 512-373-4010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BENJAMIN D SUPNET
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 512-373-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | L3152
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------