Provider Demographics
NPI:1568899581
Name:AUGUSTINE HEALTH GROUP
Entity Type:Organization
Organization Name:AUGUSTINE HEALTH GROUP
Other - Org Name:PROVIDENCE SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-472-2741
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 1:1655 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:803-409-7130
Practice Address - Fax:803-252-8280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-04
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty