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General NPI Number Information
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NPI Number | 1659885754
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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 | 11/28/2017
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Last Update Date | 12/17/2018
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Provider Practice Location Address
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Address Line | 114 GATEWAY CORPORATE BLVD STE 440
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City | COLUMBIA
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State | SC
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Zip | 29203-9785
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Country | US
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Telephone | 803-365-8620
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Fax | 803-365-8629
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Provider Business Mailing Address
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Address Line | 330 SEVEN SPRINGS WAY
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City | BRENTWOOD
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State | TN
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Zip | 37027-5098
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Country | US
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Telephone | 615-920-7000
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Fax | 615-920-8775
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Authorized Official
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Title or Position | DIRECTOR
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Name | SARA L MILLER
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Credential |
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Telephone | 615-920-7514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology 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 | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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