Healthcare Provider Details

I. General information

NPI: 1689030595
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 LAUREL ST STE 300
COLUMBIA SC
29204-1018
US

IV. Provider business mailing address

114 GATEWAY CORPORATE BLVD STE 425
COLUMBIA SC
29203-9740
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-2786
  • Fax:
Mailing address:
  • Phone: 803-865-4780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHY TEAGUE
Title or Position: AVP, SECRETARY
Credential:
Phone: 615-920-7000