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General NPI Number Information
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NPI Number | 1558710376
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Entity Type | Organization
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Legal Business Name | PROVIDENCE PHYSICIAN PRACTICES LLC
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Dates
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Enumeration Date | 06/13/2016
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Last Update Date | 02/23/2017
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Provider Practice Location Address
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Address Line | 7936 BROAD RIVER RD
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City | IRMO
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State | SC
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Zip | 29063-2355
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Country | US
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Telephone | 803-732-4001
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Fax | 803-732-2123
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Provider Business Mailing Address
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Address Line | 114 GATEWAY CORPORATE BLVD STE 425
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City | COLUMBIA
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State | SC
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Zip | 29203-9740
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Country | US
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Telephone | 803-865-4780
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JESS N JUDY
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Credential |
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Telephone | 615-920-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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