Provider Demographics
NPI:1003187071
Name:AUGUSTA ALLERGY AND ASTHMA, LLC
Entity Type:Organization
Organization Name:AUGUSTA ALLERGY AND ASTHMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-421-1700
Mailing Address - Street 1:4350 TOWNE CENTRE DR STE 1500
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3332
Mailing Address - Country:US
Mailing Address - Phone:706-421-1700
Mailing Address - Fax:706-396-0618
Practice Address - Street 1:4350 TOWNE CENTRE DR STE 1500
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3332
Practice Address - Country:US
Practice Address - Phone:706-421-1700
Practice Address - Fax:706-396-0618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045041207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABB7391155OtherDEA REGISTRATION ID
GABB7391155OtherDEA REGISTRATION ID