Provider Demographics
NPI:1417142662
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:
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:OT
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:803-227-8000
Mailing Address - Fax:
Practice Address - Street 1:104 SALUDA POINTE DRIVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-227-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA0686Medicaid
SC9533Medicare PIN
SCPA0686Medicaid