Healthcare Provider Details

I. General information

NPI: 1689034548
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 BERNARDIN AVE STE 110
COLUMBIA SC
29204-2039
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 803-409-7130
  • Fax:
Mailing address:
  • Phone: 803-865-4780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JESS JUDY
Title or Position: PRESIDENT
Credential:
Phone: 615-920-7000