Healthcare Provider Details

I. General information

NPI: 1376824920
Provider Name (Legal Business Name): PROVIDENCE CARDIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 NORTH ST
BAMBERG SC
29003-1319
US

IV. Provider business mailing address

2001 LAUREL ST
COLUMBIA SC
29204-1018
US

V. Phone/Fax

Practice location:
  • Phone: 803-245-6290
  • Fax: 803-245-6291
Mailing address:
  • Phone: 803-254-3278
  • Fax: 803-376-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN L KOENIG
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 803-254-3278