Provider Demographics
NPI:1275857856
Name:CSRA WOMENS HEALTH, LLC
Entity Type:Organization
Organization Name:CSRA WOMENS HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-922-6903
Mailing Address - Street 1:820 SAINT SEBASTIAN WAY
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2643
Mailing Address - Country:US
Mailing Address - Phone:706-432-0606
Mailing Address - Fax:706-432-0670
Practice Address - Street 1:820 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 1B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2643
Practice Address - Country:US
Practice Address - Phone:706-432-0606
Practice Address - Fax:706-432-0670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALCB19990014783174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPB033OtherSOUTH CAROLINA MEDICAID
GA004402173Medicaid
SCGPB033OtherSOUTH CAROLINA MEDICAID