Provider Demographics
NPI:1538144480
Name:MEDICAL ONCOLOGY ASSOCIATES OF AUGUSTA, PC
Entity Type:Organization
Organization Name:MEDICAL ONCOLOGY ASSOCIATES OF AUGUSTA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-722-4245
Mailing Address - Street 1:1348 WALTON WAY
Mailing Address - Street 2:SUITE 6700
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-5104
Mailing Address - Country:US
Mailing Address - Phone:706-722-4245
Mailing Address - Fax:706-722-6652
Practice Address - Street 1:1348 WALTON WAY
Practice Address - Street 2:SUITE 6700
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-5104
Practice Address - Country:US
Practice Address - Phone:706-722-4245
Practice Address - Fax:706-722-6652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16487174400000X
GA46944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00860274BMedicaid
SCG46944Medicaid
GA00151951DMedicaid
SC908726Medicaid
GA00860274BMedicaid
SC908726Medicaid
GAD30815Medicare UPIN
GA90BDBJXMedicare ID - Type UnspecifiedDR. SAMUEL CHAN