Healthcare Provider Details

I. General information

NPI: 1255308342
Provider Name (Legal Business Name): PROVIDENCE ORTHOPAEDIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEDICAL PARK RD SUITE 200
COLUMBIA SC
29203-6877
US

IV. Provider business mailing address

PO BOX 9592
BELFAST ME
04915-9592
US

V. Phone/Fax

Practice location:
  • Phone: 803-227-8152
  • Fax: 803-227-8011
Mailing address:
  • Phone: 803-227-8152
  • Fax: 803-227-8011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number570521956
License Number StateSC

VIII. Authorized Official

Name: MR. SEAN P. MCNALLY
Title or Position: CEO
Credential:
Phone: 803-227-8152