Provider Demographics
NPI:1053626168
Name:VITAE CLINIC INC
Entity type:Organization
Organization Name:VITAE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KALAMARIDES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:512-458-6060
Mailing Address - Street 1:PO BOX 301990
Mailing Address - Street 2:3507 N. LAMAR
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0034
Mailing Address - Country:US
Mailing Address - Phone:512-458-6060
Mailing Address - Fax:512-458-6070
Practice Address - Street 1:1600 W 38TH ST
Practice Address - Street 2:SUITE 115
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6400
Practice Address - Country:US
Practice Address - Phone:512-458-6060
Practice Address - Fax:512-458-6070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217737001Medicaid
TX217737001Medicaid