Healthcare Provider Details

I. General information

NPI: 1528462470
Provider Name (Legal Business Name): PROVIDENCE ORTHOPEDIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N SUMTER ST
SUMTER SC
29150-4975
US

IV. Provider business mailing address

104 SALUDA POINTE DR
LEXINGTON SC
29072-7295
US

V. Phone/Fax

Practice location:
  • Phone: 803-227-8000
  • Fax: 803-227-8015
Mailing address:
  • Phone: 803-227-8000
  • Fax: 803-227-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MATT FRICK
Title or Position: AVP, OUTPATIENT SERVICES
Credential:
Phone: 803-227-8104