=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871945691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL TEXAS MEDICAL SPECIALISTS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2016
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9715 BURNET RD BLDG 7, STE 200
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-5215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-505-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9715 BURNET RD BLDG 7, STE 200
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-5215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-505-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MS. FARAH WALTERS-BAILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-334-2739
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 30878
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------