# PROVIDENCE MEDICAL LLC

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

## Provider details

- **NPI number:** 1871312918
- **Authorized official:** AMY MCKISSICK NP (NURSE PRACTITIONER)
- **Authorized official phone:** (803) 240-2847

## Contact information

- **Practice address:** 424 LEWIS HARGETT CIR STE 250, LEXINGTON, KY 40503-3687
- **Practice address phone:** (803) 240-2847
- **Mailing address:** 1301 SUMMERVILLE AVE, COLUMBIA, SC 29201-1927
- **Mailing address phone:** (803) 240-2847

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 10/07/2024
- **Last updated:** 10/07/2024