Basic Information
| Provider Information | |||||||||
| NPI: | 1790143766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE PHYSICIAN PRACTICES LLC | ||||||||
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| OtherOrganizationName: | MIDLANDS PULMONARY, CRITICAL CARE & SLEEP MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 GATEWAY CORPORATE BLVD | ||||||||
| Address2: | STE 425 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292039740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038654780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1655 BERNARDIN AVE | ||||||||
| Address2: | STE 350 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032537575 | ||||||||
| FaxNumber: | 8032537571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2016 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | JESS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6159207000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.