| Providence Psychiatric Consults | |
|
114 Gateway Corporate Blvd Suite 425 Columbia SC 29203-9740 | |
| (803) 256-5300 | |
| Not Available |
| Full Name | Providence Psychiatric Consults |
|---|---|
| Speciality | Psychiatry & Neurology - Forensic Psychiatry |
| Location | 114 Gateway Corporate Blvd, Columbia, South Carolina |
| Authorized Official Name and Position | Jeremy W. Whitaker (MANAGER) |
| Authorized Official Contact | 8068654798 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Psychiatric Consults Po Box 60496 Charlotte NC 28260-0496 Ph: (803) 256-5300 | Providence Psychiatric Consults 114 Gateway Corporate Blvd Suite 425 Columbia SC 29203-9740 Ph: (803) 256-5300 |
| NPI Number | 1639375199 |
|---|---|
| Provider Enumeration Date | 06/22/2007 |
| Last Update Date | 04/29/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1639375199 | NPI | - | NPPES |
| GP4739 | Medicaid | SC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084F0202X | Psychiatry & Neurology - Forensic Psychiatry | 19523 (South Carolina) | Primary |
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