Healthcare Provider Details

I. General information

NPI: 1659885754
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GATEWAY CORPORATE BLVD STE 440
COLUMBIA SC
29203-9785
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 803-365-8620
  • Fax: 803-365-8629
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SARA L MILLER
Title or Position: DIRECTOR
Credential:
Phone: 615-920-7514