MEDICARE: AUSTIN DIAGNOSTIC CLINIC, PA

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	363A00000X	Physician Assistant
2	207RH0003X	Hematology & Oncology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487632618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN DIAGNOSTIC CLINIC, PA

Provider Business Mailing Address
First Line	:	12221 N MO PAC EXPY
Second Line	:	DEPT OF HEMATOLOGY/ONCOLOGY
City	:	AUSTIN
State	:	TX
Zip	:	78758-2483
Country	:	US
Telephone Number	:	512-901-4008
Fax Number	:	512-901-3908

Provider Business Practice Location Address
First Line	:	12221 N MO PAC EXPY
Second Line	:	DEPT OF HEMATOLOGY/ONCOLOGY
City	:	AUSTIN
State	:	TX
Zip	:	78758-2483
Country	:	US
Telephone Number	:	512-901-4008
Fax Number	:	512-901-3908

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	ELLEN M ANDREW
Credential	:
Telephone Number	:	512-901-4937

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	11/15/2010

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