Basic Information
Provider Information | |||||||||
NPI: | 1225407760 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AUSTIN FIVE STAR ER, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6300 LA CALMA DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787523843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124528533 | ||||||||
FaxNumber: | 2812098930 | ||||||||
Practice Location | |||||||||
Address1: | 21315 N. SH 130 | ||||||||
Address2: | BLDG. 4 | ||||||||
City: | PFLUGERVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 78660 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124528533 | ||||||||
FaxNumber: | 2812098930 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2015 | ||||||||
LastUpdateDate: | 12/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOSKOW | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5124528533 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00M5M7 | 01 | TX | BCBS | OTHER |