=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649424144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RST GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2008
-----------------------------------------------------
Last Update Date | 11/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 RIVERSIDE DR
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501-5316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-283-6152
-----------------------------------------------------
Fax | 912-283-5264
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 POWERS FERRY RD NW SUITE 600-172
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-2919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-283-6152
-----------------------------------------------------
Fax | 912-283-5264
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARCO A AYULO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 912-283-6152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------