Provider Demographics
NPI:1548466006
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:PO BOX 601964
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1964
Mailing Address - Country:US
Mailing Address - Phone:855-477-2477
Mailing Address - Fax:216-472-2740
Practice Address - Street 1:2435 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2026
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:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7682Medicare PIN