=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972612190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK H AUSTIN JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2050 WALTON WAY
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-434-1590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 13TH STREET SUITE 10
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-434-1590
-----------------------------------------------------
Fax | 706-434-1595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 032689
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------