Provider Demographics
NPI:1558827774
Name:AUGUST PEDIATRICS, LLC
Entity type:Organization
Organization Name:AUGUST PEDIATRICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO & OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-302-7015
Mailing Address - Street 1:123 N 19TH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-2865
Mailing Address - Country:US
Mailing Address - Phone:606-302-7036
Mailing Address - Fax:
Practice Address - Street 1:123 N 19TH ST STE 302
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-302-7036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-12
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0123456789OtherMI