Provider Demographics
NPI:1053605196
Name:AUGUSTINE HEALTH GROUP
Entity type:Organization
Organization Name:AUGUSTINE HEALTH GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
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 1:105 PROFESSIONAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229
Practice Address - Country:US
Practice Address - Phone:803-865-4780
Practice Address - Fax:803-865-4932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISTERS OF CHARITY PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA2264OtherRAILROAD MEDICARE GROUP NUMBER