Provider Demographics
NPI:1992133912
Name:PROVIDENCE HOSPITAL
Entity type:Organization
Organization Name:PROVIDENCE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-633-1660
Mailing Address - Street 1:3687 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6521
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:706-396-3252
Practice Address - Street 1:6801 AIRPORT BLVD
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3709
Practice Address - Country:US
Practice Address - Phone:251-631-3272
Practice Address - Fax:251-631-3273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-30
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty