Provider Demographics
NPI:1215258918
Name:AUSTIN SOUTHWEST ORTHOPAEDIC GROUP, P.A.
Entity type:Organization
Organization Name:AUSTIN SOUTHWEST ORTHOPAEDIC GROUP, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-451-1969
Mailing Address - Street 1:2500 W WILLIAM CANNON DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5257
Mailing Address - Country:US
Mailing Address - Phone:512-451-1969
Mailing Address - Fax:512-458-2327
Practice Address - Street 1:441 HWY 71 W
Practice Address - Street 2:SUITE F
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3931
Practice Address - Country:US
Practice Address - Phone:512-451-1969
Practice Address - Fax:512-458-2327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7496207X00000X, 332B00000X
TXK9864207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2103178-01Medicaid
TX0A4868Medicare PIN