Basic Information
| Provider Information | |||||||||
| NPI: | 1538667977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUSTIN DIAGNOSTIC CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744402 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129011111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2018 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | CARBONELL | ||||||||
| AuthorizedOfficialFirstName: | RODERICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIVISION VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5124824108 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.