Basic Information
Provider Information | |||||||||
NPI: | 1518072933 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AUGUSTA HEALTH CARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AMC SKYLINE INTERNAL MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 239 | ||||||||
Address2: |   | ||||||||
City: | FISHERSVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 229390239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5409324629 | ||||||||
FaxNumber: | 5409324616 | ||||||||
Practice Location | |||||||||
Address1: | 2522 JEFFERSON HWY | ||||||||
Address2: | SUITE 110 | ||||||||
City: | WAYNESBORO | ||||||||
State: | VA | ||||||||
PostalCode: | 229806500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5409417899 | ||||||||
FaxNumber: | 5409417898 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2006 | ||||||||
LastUpdateDate: | 10/17/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEERING | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5409324000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AUGUSTA HEALTH CARE, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | COO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.