Provider Demographics
NPI:1487901476
Name:AU MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:AU MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER,PIC, BANK
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:WIMPEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-723-0909
Mailing Address - Street 1:1120 15TH ST # BT1964
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-723-0900
Mailing Address - Fax:706-723-0910
Practice Address - Street 1:1120 15TH ST # BT1964
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-723-0900
Practice Address - Fax:706-723-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0098713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136200OtherPK
GA003159433AMedicaid
2136200OtherPK