Provider Demographics
NPI:1437279122
Name:AUGUSTINE HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:AUGUSTINE HEALTH GROUP, LLC
Other - Org Name:PROVIDENCE NORTHEAST FAMILY CARE
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:PO BOX 601964
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1964
Mailing Address - Country:US
Mailing Address - Phone:855-477-2477
Mailing Address - Fax:216-472-2740
Practice Address - Street 1:114 GATEWAY CORPORATE BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9740
Practice Address - Country:US
Practice Address - Phone:803-788-2277
Practice Address - Fax:803-788-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4383Medicaid
SC7682Medicare PIN