Basic Information
| Provider Information | |||||||||
| NPI: | 1154841021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROAD RIVER PHYSICIANS GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21801 | ||||||||
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| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2435 FOREST DR | ||||||||
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| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032565300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2017 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | LARSEN | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7708745400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.