Provider Demographics
NPI:1710096797
Name:MONGAN, PATRICK F (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:F
Last Name:MONGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-6410
Mailing Address - Fax:706-722-5187
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4588
Practice Address - Fax:706-721-7264
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000215982AMedicaid
GA000471809COtherGRP1619 MEDICAID FQHC
SC182166Medicaid
GA341629OtherWELLCARE GROUP
GAGRP1619OtherMEDICARE FFS
GA000467519AOtherGRP1619 MEDICAID FQHC
GA641630OtherWELLCARE GROUP
GA641630OtherWELLCARE GROUP
GAGRP1619OtherMEDICARE FFS
D46168Medicare UPIN
GA000215982AMedicaid
GA111813Medicare Oscar/Certification