Healthcare Provider Details

I. General information

NPI: 1548265838
Provider Name (Legal Business Name): WALTER KENNETH AUSTIN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 SAMARITAN DR
JASPER GA
30143-1964
US

IV. Provider business mailing address

175 SAMARITAN DR STE 100
JASPER GA
30143-1964
US

V. Phone/Fax

Practice location:
  • Phone: 706-253-4633
  • Fax: 706-253-1192
Mailing address:
  • Phone: 706-253-4633
  • Fax: 706-253-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number047049
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number047049
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number047049
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: