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General NPI Number Information
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NPI Number | 1821051392
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Entity Type | Organization
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Legal Business Name | AUGUSTINE HEALTH GROUP LLC
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Dates
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Enumeration Date | 04/07/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 114 GATEWAY CORP BLVD SUITE 350 AUGUSTINE HEALTH GROUP LLC
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City | COLUMBIA
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State | SC
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Zip | 29203-9802
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Country | US
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Telephone | 803-865-4780
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Fax | 803-865-4932
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Provider Business Mailing Address
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Address Line | 114 GATEWAY CORP BLVD SUITE 425
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City | COLUMBIA
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State | SC
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Zip | 29203-9802
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Country | US
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Telephone | 803-865-4780
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Fax | 803-865-4932
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Authorized Official
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Title or Position | MGR GENERAL ACCOUNTING
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Name | MRS. LISA B HAM
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Credential | CPA
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Telephone | 803-865-4583
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 25087
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 21388
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License Number State | SC
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