Basic Information
| Provider Information | |||||||||
| NPI: | 1912951963 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS HOSPITAL OF AUGUSTA LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DOCTORS HOSPITAL (AUGUSTA) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3651 WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309096521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066513232 | ||||||||
| FaxNumber: | 7066512041 | ||||||||
| Practice Location | |||||||||
| Address1: | 3651 WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309096521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066513232 | ||||||||
| FaxNumber: | 7066512041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERTON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7066516108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 156164500 | 01 | DEPT OF LABOR | OTHER | 174493000 | 05 | WV | MEDICAID | 191815 | 05 | FL | MEDICAID | 91401739 | 05 | CO | MEDICAID | 00000558A | 05 | GA | MEDICAID | 02718918 | 05 | NY | MEDICAID | 220545 | 05 | MS | MEDICAID | 1757641 | 05 | LA | MEDICAID | 807214700 | 05 | ID | MEDICAID | 912601 | 05 | AZ | MEDICAID | HOS0177N | 05 | AL | MEDICAID | 0044555 | 05 | NJ | MEDICAID | 138 | 01 | GA | BLUE CROSS | OTHER | 191815 | 01 | NY | WELLCARE HMO | OTHER | 356425 | 05 | SC | MEDICAID | 358867 | 05 | OH | MEDICAID | 7221 | 01 | TN | BLUECARE | OTHER | 92844500 | 05 | FL | MEDICAID | XHSP30784 | 05 | CA | MEDICAID | 1100177 | 05 | NC | MEDICAID |