Provider Demographics
NPI:1255308342
Name:PROVIDENCE ORTHOPAEDIC GROUP LLC
Entity Type:Organization
Organization Name:PROVIDENCE ORTHOPAEDIC GROUP LLC
Other - Org Name:MOORE ORTHOPAEDIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-227-8152
Mailing Address - Street 1:PO BOX 9592
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9592
Mailing Address - Country:US
Mailing Address - Phone:803-227-8152
Mailing Address - Fax:803-227-8011
Practice Address - Street 1:14 MEDICAL PARK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6877
Practice Address - Country:US
Practice Address - Phone:803-227-8152
Practice Address - Fax:803-227-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC570521956207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA0686Medicaid
SCDM0194OtherMEDICAID DME#
SC0497990001OtherMEDICARE DME#
SC0497990001Medicare NSC
SC0497990001OtherMEDICARE DME#