Provider Demographics
NPI:1194796607
Name:SISTERS OF CHARITY PROVIDENCE HOSPITALS
Entity type:Organization
Organization Name:SISTERS OF CHARITY PROVIDENCE HOSPITALS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JHO
Authorized Official - Middle Name:R
Authorized Official - Last Name:OUTLAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-454-2600
Mailing Address - Street 1:PO BOX 1467
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202
Mailing Address - Country:US
Mailing Address - Phone:803-454-2613
Mailing Address - Fax:803-765-1732
Practice Address - Street 1:2435 FOREST DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-454-2613
Practice Address - Fax:803-765-1732
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISTERS OF CHARITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-01
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3278Medicaid
SC7187Medicare PIN