Provider Demographics
NPI:1316117492
Name:FD MEDICAL I
Entity type:Organization
Organization Name:FD MEDICAL I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DORNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-502-3033
Mailing Address - Street 1:9600 GREAT HILLS TRL
Mailing Address - Street 2:STE: 150W
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-6387
Mailing Address - Country:US
Mailing Address - Phone:512-502-3033
Mailing Address - Fax:866-776-6641
Practice Address - Street 1:9600 GREAT HILLS TRL
Practice Address - Street 2:STE: 150W
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-6387
Practice Address - Country:US
Practice Address - Phone:512-502-3033
Practice Address - Fax:866-776-6641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty