=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801317904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUSTIN KIDNEY ASSOCIATES, P. A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2017
-----------------------------------------------------
Last Update Date | 05/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8620 BURNET RD STE 400
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78757-7034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-334-1810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 E HIGHLAND MALL BLVD STE 1A
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78752-3746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | DIVYA DIWAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-458-5800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------