MEDICARE: PROVIDENCE HOSPITAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	ASF058	SC
2	282N00000X	General Acute Care Hospital	HTL821	SC
3	282N00000X	General Acute Care Hospital	HTL820	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003811290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HOSPITAL, LLC

Provider Business Mailing Address
First Line	:	330 SEVEN SPRINGS WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-5098
Country	:	US
Telephone Number	:	615-920-7000
Fax Number	:	615-920-8913

Provider Business Practice Location Address
First Line	:	2435 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2026
Country	:	US
Telephone Number	:	803-256-5300
Fax Number	:	803-256-5935

Authorized Official
Title or Position	:	ASSISTANT VICE PRESIDENT, SECRETARY
Name	:	KATHY J. TEAGUE
Credential	:
Telephone Number	:	615-920-7000

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	03/22/2021

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Directions to “PROVIDENCE HOSPITAL, LLC ” Practice Location

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