Basic Information
| Provider Information | |||||||||
| NPI: | 1194028019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE ER SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 96088 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731436088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002250953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2435 FOREST DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032565300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8038654850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.