MEDICARE: BASTROP BLACKHAWK 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	261QM1300X	Multi-Specialty Clinic/Center
2	282N00000X	General Acute Care Hospital	008314	TX

General Provider Information

NPI Number	:	1881823151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASTROP BLACKHAWK LLC

Provider Business Mailing Address
First Line	:	3201 HIGHWAY 71 E
Second Line	:
City	:	BASTROP
State	:	TX
Zip	:	78602-5126
Country	:	US
Telephone Number	:	512-321-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 HIGHWAY 71 E
Second Line	:
City	:	BASTROP
State	:	TX
Zip	:	78602-5126
Country	:	US
Telephone Number	:	512-321-8200
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/OFFICER
Name	:	TODD F BIEDERMAN
Credential	:
Telephone Number	:	512-681-3440

Provider Enumeration Date	:	07/08/2009
Last Update Date	:	11/23/2009

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Directions to “BASTROP BLACKHAWK LLC ” Practice Location

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