MEDICARE: SOUTH AUSTIN ENDOCRINOLOGY AND OBESITY CLINIC PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1023769387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH AUSTIN ENDOCRINOLOGY AND OBESITY CLINIC PLLC

Provider Business Mailing Address
First Line	:	1340 WONDER WORLD DR STE 2203
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-7791
Country	:	US
Telephone Number	:	512-969-8991
Fax Number	:	512-982-6186

Provider Business Practice Location Address
First Line	:	1340 WONDER WORLD DR STE 2203
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-7791
Country	:	US
Telephone Number	:	512-969-8991
Fax Number	:	512-982-6186

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SIMONA RICHEH
Credential	:
Telephone Number	:	773-742-0081

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	01/18/2022

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