Provider Demographics
NPI:1518087287
Name:AUGUSTINE HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:AUGUSTINE HEALTH GROUP, LLC
Other - Org Name:PROVIDENCE INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:803-865-4798
Mailing Address - Street 1:PO BOX 60496
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0496
Mailing Address - Country:US
Mailing Address - Phone:803-254-4056
Mailing Address - Fax:803-254-4120
Practice Address - Street 1:1655 BERNARDIN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2039
Practice Address - Country:US
Practice Address - Phone:803-254-4056
Practice Address - Fax:803-254-4120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4662Medicaid
SCGP4662Medicaid