1104165091 NPI number — CAPITAL ARTHROSCOPY SPORTS MEDICINE TRAUMA SURGERY PA

Table of content: (NPI 1104165091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104165091 NPI number — CAPITAL ARTHROSCOPY SPORTS MEDICINE TRAUMA SURGERY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL ARTHROSCOPY SPORTS MEDICINE TRAUMA SURGERY PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1104165091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 302405
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78703-0041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-720-8215
Provider Business Mailing Address Fax Number:
281-254-7864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4112 LINKS LN
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78664-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-720-8215
Provider Business Practice Location Address Fax Number:
281-254-7864
Provider Enumeration Date:
02/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DUGGAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
ORTHOPEDIC SURGEON
Authorized Official Telephone Number:
512-364-6562

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  M9262 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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