MEDICARE: PROVIDENCE ORTHOPAEDIC GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	570521956	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	0497990001	OTHER	SC	MEDICARE DME#

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255308342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE ORTHOPAEDIC GROUP LLC

Provider Business Mailing Address
First Line	:	PO BOX 9592
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-9592
Country	:	US
Telephone Number	:	803-227-8152
Fax Number	:	803-227-8011

Provider Business Practice Location Address
First Line	:	14 MEDICAL PARK RD
Second Line	:	SUITE 200
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6877
Country	:	US
Telephone Number	:	803-227-8152
Fax Number	:	803-227-8011

Authorized Official
Title or Position	:	CEO
Name	:	MR. SEAN P. MCNALLY
Credential	:
Telephone Number	:	803-227-8152

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	10/22/2010

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Directions to “PROVIDENCE ORTHOPAEDIC GROUP LLC ” Practice Location

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