Provider Demographics
NPI:1508036203
Name:AUGUSTINE HEALTH GROUP LLC
Entity Type:Organization
Organization Name:AUGUSTINE HEALTH GROUP LLC
Other - Org Name:PROVIDENCE PHYSICAL MEDICINE AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:FRAME
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 440
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 1:114 GATEWAY CORPORATE BLVD
Practice Address - Street 2:SUITE 440
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-865-4780
Practice Address - Fax:803-865-4932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUGUSTINE HEALTH GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4785Medicaid
SC7682Medicare PIN