Basic Information
| Provider Information | |||||||||
| NPI: | 1841675980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE STAR ER LLC | ||||||||
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| 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: | 8721 MANCHACA ROAD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124528533 | ||||||||
| FaxNumber: | 2812098930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | CONNER | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5124528533 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 160191 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | HH192E | 01 | TX | BCBS | OTHER |