Basic Information
| Provider Information | |||||||||
| NPI: | 1700851920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AUGUSTA HEALTH CARE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOSPICE OF THE SHENANDOAH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 215 | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229390215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409324943 | ||||||||
| FaxNumber: | 5409324616 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 SPORTS MEDICINE DR | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409324943 | ||||||||
| FaxNumber: | 5409324616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KATSIANIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5409324684 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 337475 | 01 | VA | ANTHEM | OTHER | 4910354 | 05 | VA | MEDICAID |