Provider Demographics
NPI:1558710376
Name:PROVIDENCE PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICIAN PRACTICES LLC
Other - Org Name:THREE RIVERS MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:114 GATEWAY CORPORATE BLVD
Mailing Address - Street 2:STE 425
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9740
Mailing Address - Country:US
Mailing Address - Phone:803-865-4780
Mailing Address - Fax:
Practice Address - Street 1:7936 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2355
Practice Address - Country:US
Practice Address - Phone:803-732-4001
Practice Address - Fax:803-732-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty