Provider Demographics
NPI:1194790451
Name:AUSTIN DIAGNOSTIC CLINIC, PA
Entity type:Organization
Organization Name:AUSTIN DIAGNOSTIC CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-901-4937
Mailing Address - Street 1:12221 MOPAC EXPRESSWAY NORTH
Mailing Address - Street 2:DEPT OF IMAGING SERVICES
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2483
Mailing Address - Country:US
Mailing Address - Phone:512-901-8729
Mailing Address - Fax:512-901-8755
Practice Address - Street 1:12221 MOPAC EXPRESSWAY NORTH
Practice Address - Street 2:DEPT OF IMAGING SERVICES
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2483
Practice Address - Country:US
Practice Address - Phone:512-901-8729
Practice Address - Fax:512-901-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140347945Medicaid
TX00DG69Medicare PIN
TXCP9039Medicare PIN
TX0807840001Medicare NSC