Organization
PROVIDENCE ORTHOPAEDIC GROUP
Active
Other names
Moore Orthopaedic Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
MR. SEAN MCNALLY (CEO)
(803) 227-8152
Entity
Organization
Contact information
Practice address
4721 SUNSET BLVD, SUITE A, LEXINGTON, SC 29072-9151
(803) 227-8007
(803) 996-3180
Mailing address
P.O. BOX 843384, BOSTON, MA 02284-3384
(803) 227-8007
(803) 996-3180
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
570521956
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14979900001
MEDICARE DME#
SC
01
—
570521956-009
BC/BS PROVIDER #
SC
01
—
DM0194
MEDICAID DME#
SC
05
—
PA0686
—
SC
Enumeration date
06/07/2006
Last updated
06/29/2010
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