Healthcare Provider Details

I. General information

NPI: 1144523051
Provider Name (Legal Business Name): AUGUSTINE HEALTH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GATEWAY CORPORATE BLVD SUITE 330
COLUMBIA SC
29203-9740
US

IV. Provider business mailing address

114 GATEWAY CORPORATE BLVD SUITE 425
COLUMBIA SC
29203-9740
US

V. Phone/Fax

Practice location:
  • Phone: 803-865-4514
  • Fax: 803-865-4932
Mailing address:
  • Phone: 803-865-4780
  • Fax: 803-865-4932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA HAITHCOCK
Title or Position: PROJECT MANAGER
Credential:
Phone: 803-865-4780