Basic Information
| Provider Information | |||||||||
| NPI: | 1215946850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAUSTIAN | ||||||||
| FirstName: | PHILIP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 403631 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303843631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707400895 | ||||||||
| FaxNumber: | 7707400896 | ||||||||
| Practice Location | |||||||||
| Address1: | 2626 CAPITAL MEDICAL BLVD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503255885 | ||||||||
| FaxNumber: | 8503257685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 12/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 026615 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME45564 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 52047617022 | 01 | GA | BCBS | OTHER | 14149 | 01 | FL | FL BCBS | OTHER | P00377668 | 01 | GA | RAIL ROAD MEDICARE | OTHER | 001371200 | 05 | FL | MEDICAID | 427196341A | 05 | GA | MEDICAID |