Provider Demographics
NPI:1962104521
Name:CHILDREN'S MEDICAL GROUP OF AUSTIN
Entity type:Organization
Organization Name:CHILDREN'S MEDICAL GROUP OF AUSTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:EDRY SALEK
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-535-8243
Mailing Address - Street 1:631 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1250
Mailing Address - Country:US
Mailing Address - Phone:512-451-5161
Mailing Address - Fax:
Practice Address - Street 1:631 W 38TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1250
Practice Address - Country:US
Practice Address - Phone:512-451-5161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1003043134Medicaid
TX1366776031Medicaid
TX1801460225Medicaid
TX1801896246Medicaid