Provider Demographics
NPI:1174561864
Name:MORALES, AUGUSTO (MD)
Entity type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:
Last Name:MORALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:200 PATEWOOD DR STE A350
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3547
Practice Address - Country:US
Practice Address - Phone:864-454-5110
Practice Address - Fax:864-241-9206
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC191302084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT30810Medicaid
SCT30810Medicaid
SCD166767951Medicare PIN
SCD16676Medicare UPIN
SCD166767951Medicare PIN
SC2028313OtherCIGNA
SC576007863094OtherBCBS OF SC
SCD166766904Medicare PIN