=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225225014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUGUSTA PRIMARY CARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 06/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3623 J DEWEY GRAY CIR SUITE 210
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-6511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-922-7670
-----------------------------------------------------
Fax | 706-922-7680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3623 J DEWEY GRAY CIR SUITE 210
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-6511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-922-7670
-----------------------------------------------------
Fax | 706-922-7680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | DR. PRAKASH MANIAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 706-922-7670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 27620
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------