Basic Information
| Provider Information | |||||||||
| NPI: | 1861566838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUGUSTA CARDIOLOGY CLINIC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 818 SAINT SEBASTIAN WAY STE 311 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067243473 | ||||||||
| FaxNumber: | 7067243493 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 SAINT SEBASTIAN WAY STE 311 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067243473 | ||||||||
| FaxNumber: | 7067243493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7067243473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | GPA513 | 05 | SC | MEDICAID |