Healthcare Provider Details

I. General information

NPI: 1366519530
Provider Name (Legal Business Name): PROVIDENT HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MALLET WAY
BLUFFTON SC
29910-6064
US

IV. Provider business mailing address

PO BOX 933213
ATLANTA GA
31193-1968
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-7412
  • Fax: 912-350-7297
Mailing address:
  • Phone: 912-350-7412
  • Fax: 912-350-7297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBIN J. MADDOX
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 912-350-9335