Provider Demographics
NPI:1770941742
Name:PROVIDENCE PHYSICIAN PRACTICES LLC
Entity type:Organization
Organization Name:PROVIDENCE PHYSICIAN PRACTICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:
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 1:2750 LAUREL ST
Practice Address - Street 2:STE 305
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2038
Practice Address - Country:US
Practice Address - Phone:803-254-5140
Practice Address - Fax:803-779-1279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty