Provider Demographics
NPI:1154514313
Name:MICHAEL F. VANDEWALLE P.C.
Entity type:Organization
Organization Name:MICHAEL F. VANDEWALLE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:VANDEWALLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-343-0700
Mailing Address - Street 1:11824 JOLLYVILLE RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2322
Mailing Address - Country:US
Mailing Address - Phone:512-343-0700
Mailing Address - Fax:512-343-0775
Practice Address - Street 1:11824 JOLLYVILLE RD
Practice Address - Street 2:SUITE 500
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-2322
Practice Address - Country:US
Practice Address - Phone:512-343-0700
Practice Address - Fax:512-343-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2771111N00000X
TX11404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P0221OtherBCBS
TX11404OtherCHIROPRACTIC LICENSE
TXC06060612Medicaid
TX2771OtherSTATE LICENSE
TX0A5591Medicare PIN
TXC06060612Medicaid