Provider Demographics
NPI:1780998161
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:PROJECT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAITHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-865-4780
Mailing Address - Street 1:114 GATEWAY CORPORATE BLVD
Mailing Address - Street 2:SUITE 425
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9740
Mailing Address - Country:US
Mailing Address - Phone:803-865-4780
Mailing Address - Fax:803-865-4932
Practice Address - Street 1:2601 LAUREL ST
Practice Address - Street 2:SUITE 120
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2033
Practice Address - Country:US
Practice Address - Phone:803-254-7889
Practice Address - Fax:803-254-7893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC052052Medicaid
SC052052Medicaid