=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558606533
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUSTIN DERMPATH ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2012
-----------------------------------------------------
Last Update Date | 12/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3010 WILLIAMS DRIVE SUITE 174
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-2785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-868-3376
-----------------------------------------------------
Fax | 512-240-5469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3010 WILLIAMS DRIVE SUITE 210
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-2787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-868-3376
-----------------------------------------------------
Fax | 512-240-5469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ERIC ADRIEN ADELMAN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 512-868-3376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------