Provider Demographics
NPI:1740484658
Name:AUGUSTINE HEALTH GROUP, LLC
Entity type:Organization
Organization Name:AUGUSTINE HEALTH GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:CPC
Authorized Official - Phone:803-865-4798
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:803-256-5460
Mailing Address - Fax:
Practice Address - Street 1:120 GATEWAY CORPORATE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9611
Practice Address - Country:US
Practice Address - Phone:803-256-5460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4709Medicaid
SCGP4709Medicaid