Organization
PROVIDENCE PHYSICIAN PRACTICES LLC
Active
Other names
PROVIDENCE SURGICAL ASSOCIATES
Organization subpart
No
Provider details
NPI number
Authorized official
JESS JUDY (PRESIDENT)
(615) 920-7000
Entity
Organization
Contact information
Practice address
1655 BERNARDIN AVE, STE 110, COLUMBIA, SC 29204-2039
(803) 409-7130
Mailing address
114 GATEWAY CORPORATE BLVD, STE 425, COLUMBIA, SC 29203-9740
(803) 865-4780
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
—
—
208600000X
Surgery Physician
Primary
—
—
2086S0122X
Plastic and Reconstructive Surgery Physician
—
—
Other
Enumeration date
03/04/2016
Last updated
02/22/2017
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