=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558307660
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS ROBERT AUSTGEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 06/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1370 13TH AVE S SUITE 116
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-247-3858
-----------------------------------------------------
Fax | 904-247-7079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11945 SAN JOSE BLVD BLDG 300
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-396-1725
-----------------------------------------------------
Fax | 904-399-1717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | ME95091
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------