Provider Demographics
NPI:1336497742
Name:PROVIDENCE CARDIOLOGY LLC
Entity Type:Organization
Organization Name:PROVIDENCE CARDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-254-3278
Mailing Address - Street 1:2001 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1018
Mailing Address - Country:US
Mailing Address - Phone:803-254-3278
Mailing Address - Fax:803-376-8010
Practice Address - Street 1:114 GATEWAY CORPORATE BLVD
Practice Address - Street 2:SUITE 330
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9740
Practice Address - Country:US
Practice Address - Phone:803-254-3278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE CARDIOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA407Medicare PIN