1033374244 NPI number — PROVIDENCE ORTHOPAEDIC GROUP, LLC

Table of content: (NPI 1033374244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033374244 NPI number — PROVIDENCE ORTHOPAEDIC GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE ORTHOPAEDIC GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033374244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843384
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-3384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-227-8004
Provider Business Mailing Address Fax Number:
803-781-7338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE WELLNESS BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
IRMO
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-227-8004
Provider Business Practice Location Address Fax Number:
803-781-7334
Provider Enumeration Date:
07/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCNALLY
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
803-227-8152

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 570521956 . This is a "TAX ID#" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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