Provider Demographics
NPI:1689944738
Name:PROVIDENCE HEALTH NETWORK, LLC
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH NETWORK, LLC
Other - Org Name:COLUMBIA MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAITHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-865-4780
Mailing Address - Street 1:114 GATEWAY CORPORATE BLVD
Mailing Address - Street 2:SUITE 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:803-865-4932
Practice Address - Street 1:2750 LAUREL ST
Practice Address - Street 2:SUITE 303
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2038
Practice Address - Country:US
Practice Address - Phone:803-252-1953
Practice Address - Fax:803-256-0138
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISTERS OF CHARITY PROVIDENCE HOSPITALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty