MEDICARE: AUSTIN CHILDREN'S SHELTER

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	207Q00000X	Family Medicine Physician	E8749	TX

General Provider Information

NPI Number	:	1730303561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN CHILDREN'S SHELTER

Provider Business Mailing Address
First Line	:	804 RIO GRANDE ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78701-2201
Country	:	US
Telephone Number	:	512-499-0090
Fax Number	:	512-499-0438

Provider Business Practice Location Address
First Line	:	1501 ENFIELD RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78703-3404
Country	:	US
Telephone Number	:	512-499-0090
Fax Number	:	512-499-0438

Authorized Official
Title or Position	:	DEPUTY DIRECTOR OF FINANCE
Name	:	MR. JERRY FYE
Credential	:
Telephone Number	:	512-499-0090

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	09/04/2007

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