| Providence Family Medicine Clemson Road | |
|
105 Professional Park Drive Columbia SC 29229 | |
| (803) 865-4780 | |
| (803) 865-4932 |
| Full Name | Providence Family Medicine Clemson Road |
|---|---|
| Speciality | Family Medicine |
| Location | 105 Professional Park Drive, Columbia, South Carolina |
| Authorized Official Name and Position | Angela Haithcock (CREDENTIALING COORDINATOR) |
| Authorized Official Contact | 8038654780 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Family Medicine Clemson Road 114 Gateway Corporate Blvd Suite 425 Columbia SC 29203-9740 Ph: (803) 865-4780 | Providence Family Medicine Clemson Road 105 Professional Park Drive Columbia SC 29229 Ph: (803) 865-4780 |
| NPI Number | 1053605196 |
|---|---|
| Provider Enumeration Date | 06/07/2011 |
| Last Update Date | 06/07/2011 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053605196 | NPI | - | NPPES |
| DA2264 | Other | SC | RAILROAD MEDICARE GROUP NUMBER |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (South Carolina) | Primary |
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