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General NPI Number Information
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NPI Number | 1659921740
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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 | 09/19/2019
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Last Update Date | 12/09/2019
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Provider Practice Location Address
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Address Line | 216 E MARION ST
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City | KERSHAW
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State | SC
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Zip | 29067-1442
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Country | US
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Telephone | 803-475-3350
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Fax | 803-475-5360
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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 | 615-920-7782
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Fax | 615-920-8775
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Authorized Official
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Title or Position | CORPORATE SECRETARY
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Name | KATHY TEAGUE
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Credential |
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Telephone | 615-920-7646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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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 | 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 #3
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #9
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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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