Healthcare Provider Details

I. General information

NPI: 1285674572
Provider Name (Legal Business Name): PROVIDENCE ORTHOPAEDIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 SUNSET BLVD SUITE A
LEXINGTON SC
29072-9151
US

IV. Provider business mailing address

P.O. BOX 843384
BOSTON MA
02284-3384
US

V. Phone/Fax

Practice location:
  • Phone: 803-227-8007
  • Fax: 803-996-3180
Mailing address:
  • Phone: 803-227-8007
  • Fax: 803-996-3180

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 MCNALLY
Title or Position: CEO
Credential:
Phone: 803-227-8152