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Organization
PROVIDENCE ORTHOPAEDIC GROUP LLC
Active
Organization
PROVIDENCE ORTHOPAEDIC GROUP LLC
Active
Other names
Moore Orthopaedic Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
MR. SEAN P. MCNALLY (CEO)
(803) 227-8152
Entity
Organization
Contact information
Practice address
14 MEDICAL PARK RD, SUITE 200, COLUMBIA, SC 29203-6877
(803) 227-8152
(803) 227-8011
Mailing address
PO BOX 9592, BELFAST, ME 04915-9592
(803) 227-8152
(803) 227-8011
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
570521956
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0497990001
MEDICARE DME#
SC
01
—
DM0194
MEDICAID DME#
SC
05
—
PA0686
—
SC
Enumeration date
03/07/2006
Last updated
10/22/2010
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