Provider Demographics
NPI:1962827063
Name:PROVIDENCE ORTHOPEDIC GROUP, LLC
Entity type:Organization
Organization Name:PROVIDENCE ORTHOPEDIC GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AVP, OUTPATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:FRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-227-8104
Mailing Address - Street 1:104 SALUDA POINTE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7295
Mailing Address - Country:US
Mailing Address - Phone:803-227-8000
Mailing Address - Fax:803-227-8015
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6849
Practice Address - Country:US
Practice Address - Phone:803-227-8000
Practice Address - Fax:803-227-8015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty