Healthcare Provider Details

I. General information

NPI: 1114123122
Provider Name (Legal Business Name): ROSE C AUGUSTINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 BROADRICK DR
DALTON GA
30720-3012
US

IV. Provider business mailing address

1610 BROADRICK DR
DALTON GA
30720-3012
US

V. Phone/Fax

Practice location:
  • Phone: 706-279-1994
  • Fax: 706-279-9229
Mailing address:
  • Phone: 706-279-1994
  • Fax: 706-279-9229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number062465
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: