Provider Demographics
NPI:1093966400
Name:AUGUSTINE HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:AUGUSTINE HEALTH GROUP, LLC
Other - Org Name:ASSOCIATES IN INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAITHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-865-4780
Mailing Address - Street 1:114 GATEWAY CORPORATE BLVD.
Mailing Address - Street 2:SUITE #425
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-865-4780
Mailing Address - Fax:803-865-4932
Practice Address - Street 1:2701 MIDDLEBURG DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-254-2786
Practice Address - Fax:803-254-9015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUGUSTINE HEALTH GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-03
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7682Medicare UPIN