MEDICARE: AEC ER 4 LLC

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	261QE0002X	Emergency Care Clinic/Center

General Provider Information

NPI Number	:	1750865069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEC ER 4 LLC

Provider Business Mailing Address
First Line	:	4015 S LAMAR BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704
Country	:	US
Telephone Number	:	972-345-3470
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 E 51ST ST BLDG H
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78723-3434
Country	:	US
Telephone Number	:	972-345-3470
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR PHYSICIAN / PATIENT RELATI
Name	:	JODY HARDY
Credential	:
Telephone Number	:	972-345-3470

Provider Enumeration Date	:	09/21/2018
Last Update Date	:	09/21/2018

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