MEDICARE: NEUROLOGY AND ELECTROMYOGRAPHY CLINIC

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	2084N0400X	Neurology Physician	L2112	TX

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
2	00579T	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1912183641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROLOGY AND ELECTROMYOGRAPHY CLINIC

Provider Business Mailing Address
First Line	:	4201 MARATHON BLVD
Second Line	:	STE 304
City	:	AUSTIN
State	:	TX
Zip	:	78756-3410
Country	:	US
Telephone Number	:	512-371-1200
Fax Number	:

Provider Business Practice Location Address
First Line	:	4201 MARATHON BLVD
Second Line	:	STE 304
City	:	AUSTIN
State	:	TX
Zip	:	78756-3436
Country	:	US
Telephone Number	:	512-371-1200
Fax Number	:

Authorized Official
Title or Position	:	ACCOUNT MANAGER
Name	:	GARY CAMPBELL
Credential	:
Telephone Number	:	512-674-9002

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	12/19/2011

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