Healthcare Provider Details

I. General information

NPI: 1073833489
Provider Name (Legal Business Name): PROVIDENCE PULMONARY SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 BERNARDIN AVE SUITE 350
COLUMBIA SC
29204-2039
US

IV. Provider business mailing address

1655 BERNARDIN AVE SUITE 350
COLUMBIA SC
29204-2039
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-7575
  • Fax: 803-256-7573
Mailing address:
  • Phone: 803-256-7575
  • Fax: 803-256-7573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAWN PATTON
Title or Position: CONTROLLER
Credential:
Phone: 803-865-4850