# PROVIDENCE PHYSICIAN PRACTICES LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1659921740
- **Authorized official:** KATHY TEAGUE (CORPORATE SECRETARY)
- **Authorized official phone:** (615) 920-7646

## Contact information

- **Practice address:** 216 E MARION ST, KERSHAW, SC 29067-1442
- **Practice address phone:** (803) 475-3350
- **Practice address fax:** (803) 475-5360
- **Mailing address:** 330 SEVEN SPRINGS WAY, BRENTWOOD, TN 37027-5098
- **Mailing address phone:** (615) 920-7782
- **Mailing address fax:** (615) 920-8775

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 152W00000X | Optometrist | — | NULL | — |
| 152W00000X | Optometrist | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207R00000X | Internal Medicine Physician | — | NULL | Yes |
| 207R00000X | Internal Medicine Physician | — | — | Yes |
| 207RC0000X | Cardiovascular Disease Physician | — | NULL | — |
| 207RC0000X | Cardiovascular Disease Physician | — | — | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | NULL | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | — | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | NULL | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | — | — |
| 207W00000X | Ophthalmology Physician | — | NULL | — |
| 207W00000X | Ophthalmology Physician | — | — | — |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 363LG0600X | Gerontology Nurse Practitioner | — | NULL | — |
| 363LG0600X | Gerontology Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 09/19/2019
- **Last updated:** 12/09/2019