Healthcare Provider Details

I. General information

NPI: 1871887513
Provider Name (Legal Business Name): PULMONARY ALLERGY & SLEEP CENTER OF AUGUSTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2011
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 J DEWEY GRAY CIR
AUGUSTA GA
30909-1867
US

IV. Provider business mailing address

3630 J DEWEY GRAY CIR
AUGUSTA GA
30909-1867
US

V. Phone/Fax

Practice location:
  • Phone: 706-855-6130
  • Fax: 706-855-6139
Mailing address:
  • Phone: 706-855-6130
  • Fax: 706-855-6139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number048731
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number048366
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number048366
License Number StateGA

VIII. Authorized Official

Name: CARMEL JOSEPH
Title or Position: OWNER
Credential: M.D.
Phone: 706-855-6130