Provider Demographics
NPI:1033374244
Name:PROVIDENCE ORTHOPAEDIC GROUP, LLC
Entity Type:Organization
Organization Name:PROVIDENCE ORTHOPAEDIC GROUP, LLC
Other - Org Name:MOORE ORTHOPAEDIC CLINIC, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-227-8152
Mailing Address - Street 1:PO BOX 843384
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3384
Mailing Address - Country:US
Mailing Address - Phone:803-227-8004
Mailing Address - Fax:803-781-7338
Practice Address - Street 1:ONE WELLNESS BOULEVARD
Practice Address - Street 2:SUITE 204
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-227-8004
Practice Address - Fax:803-781-7334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570521956OtherTAX ID#