Provider Demographics
NPI:1639375199
Name:AUGUSTINE HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:AUGUSTINE HEALTH GROUP, LLC
Other - Org Name:PROVIDENCE PSYCHIATRIC CONSULTS
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:
Authorized Official - Phone:806-865-4798
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:803-256-5300
Mailing Address - Fax:
Practice Address - Street 1:114 GATEWAY CORPORATE BLVD
Practice Address - Street 2:SUITE 425
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9740
Practice Address - Country:US
Practice Address - Phone:803-256-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC195232084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4739Medicaid
SCGP4739Medicaid