Healthcare Provider Details

I. General information

NPI: 1780142968
Provider Name (Legal Business Name): AUGUST PEDIATRICS TEENS N TOTS PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N 19TH ST STE 302
MIDDLESBORO KY
40965-2865
US

IV. Provider business mailing address

123 N 19TH ST STE 302
MIDDLESBORO KY
40965-2865
US

V. Phone/Fax

Practice location:
  • Phone: 606-302-7036
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBIN CLINE
Title or Position: OFFICE MANAGER
Credential:
Phone: --2