Basic Information
Provider Information | |||||||||
NPI: | 1053335828 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITLOCK | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | RALSTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1348 WALTON WAY | ||||||||
Address2: | SUITE 5100 | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309015104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067248611 | ||||||||
FaxNumber: | 7067246202 | ||||||||
Practice Location | |||||||||
Address1: | 1348 WALTON WAY | ||||||||
Address2: | SUITE 5100 | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309015104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067248611 | ||||||||
FaxNumber: | 7067246202 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2006 | ||||||||
LastUpdateDate: | 02/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 020623 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 7340 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | G20623 | 05 | SC |   | MEDICAID | 00179077D | 05 | GA |   | MEDICAID | 1585885-004 | 01 | GA | CIGNA | OTHER | 4134155 | 01 |   | AETNA PPO | OTHER | 595429 | 01 | GA | BCBS | OTHER | 897824 | 01 |   | AETNA HMO | OTHER |