Provider Demographics
NPI:1285674572
Name:PROVIDENCE ORTHOPAEDIC GROUP
Entity type:Organization
Organization Name:PROVIDENCE ORTHOPAEDIC GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-227-8152
Mailing Address - Street 1:P.O. BOX 843384
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3384
Mailing Address - Country:US
Mailing Address - Phone:803-227-8007
Mailing Address - Fax:803-996-3180
Practice Address - Street 1:4721 SUNSET BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9151
Practice Address - Country:US
Practice Address - Phone:803-227-8007
Practice Address - Fax:803-996-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC570521956207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0194OtherMEDICAID DME#
SCPA0686Medicaid
SC14979900001OtherMEDICARE DME#
SC570521956-009OtherBC/BS PROVIDER #
SC14979900001OtherMEDICARE DME#