Healthcare Provider Details

I. General information

NPI: 1003187071
Provider Name (Legal Business Name): AUGUSTA ALLERGY AND ASTHMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 TOWNE CENTRE DR STE 1500
EVANS GA
30809-3332
US

IV. Provider business mailing address

4350 TOWNE CENTRE DR STE 1500
EVANS GA
30809-3332
US

V. Phone/Fax

Practice location:
  • Phone: 706-421-1700
  • Fax: 706-396-0618
Mailing address:
  • Phone: 706-421-1700
  • Fax: 706-396-0618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number045041
License Number StateGA

VIII. Authorized Official

Name: TRACIE BROOME
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 706-421-1700