Provider Demographics
NPI:1700071784
Name:KATTINE, TARA (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:KATTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 J DEWEY GRAY CIR STE B
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6512
Mailing Address - Country:US
Mailing Address - Phone:706-504-4651
Mailing Address - Fax:706-504-4639
Practice Address - Street 1:3614 J DEWEY GRAY CIR STE B
Practice Address - Street 2:2ND FLOOR
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6512
Practice Address - Country:US
Practice Address - Phone:706-504-4651
Practice Address - Fax:706-504-4639
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043671207R00000X, 207RH0002X
SC19771207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00815526FMedicaid
GA00815526DMedicaid
G87814Medicare UPIN
GA00815526FMedicaid
GA202I116796Medicare UPIN