Provider Demographics
NPI:1194053496
Name:JACK MONCRIEF GROUP, PA
Entity type:Organization
Organization Name:JACK MONCRIEF GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:WESLY
Authorized Official - Last Name:MONCRIEF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-485-7870
Mailing Address - Street 1:800 WEST 34TH STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705
Mailing Address - Country:US
Mailing Address - Phone:512-485-7870
Mailing Address - Fax:512-485-7876
Practice Address - Street 1:800 WEST 34TH STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-485-7870
Practice Address - Fax:512-485-7876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1311987-04Medicaid
TX1311987-04Medicaid
0054BLMedicare PIN