Healthcare Provider Details

I. General information

NPI: 1902264971
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 LAUREL ST STE 104
COLUMBIA SC
29204-2038
US

IV. Provider business mailing address

2750 LAUREL ST STE 104
COLUMBIA SC
29204-2038
US

V. Phone/Fax

Practice location:
  • Phone: 803-799-9035
  • Fax: 803-799-9710
Mailing address:
  • Phone: 803-799-9035
  • Fax: 803-799-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

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