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NPI Code Detail

MEDICARE: PROVIDENT HEALTH SERVICES, INC.

MEDICARE: PROVIDENT HEALTH SERVICES, INC.
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
12086X0206XSurgical Oncology Physician
2208600000XSurgery Physician

General Provider Information

NPI Number : 1366519530
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROVIDENT HEALTH SERVICES, INC.
Provider Business Mailing Address
First Line : PO BOX 933213
Second Line :
City : ATLANTA
State : GA
Zip : 31193-1968
Country : US
Telephone Number : 912-350-7412
Fax Number : 912-350-7297
Provider Business Practice Location Address
First Line : 7 MALLET WAY
Second Line :
City : BLUFFTON
State : SC
Zip : 29910-6064
Country : US
Telephone Number : 912-350-7412
Fax Number : 912-350-7297
Authorized Official
Title or Position : PROVIDER ENROLLMENT COORDINATOR
Name : ROBIN J. MADDOX
Credential :
Telephone Number : 912-350-9335
Provider Enumeration Date : 11/30/2006
Last Update Date : 09/11/2025

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Directions to “PROVIDENT HEALTH SERVICES, INC. ” Practice Location

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