Healthcare Provider Details

I. General information

NPI: 1174561864
Provider Name (Legal Business Name): AUGUSTO MORALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR STE A350
GREENVILLE SC
29615-3547
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-5110
  • Fax: 864-241-9206
Mailing address:
  • Phone:
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number19130
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: