=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073611992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH AUSTIN ORTHOPAEDIC CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 12/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4534 W GATE BLVD SUITE 110
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-1485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-892-1220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4534 W GATE BLVD SUITE 110
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-1485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-892-1220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CLARK RACE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 512-892-1220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------