| NPI | 1902000102 |
|---|---|
| Doing Business As | PROVIDENCE MEDICAL GROUP |
| Entity Type | Organization |
| Authorized Contact | CLARK P. CHRISTIANSON President 251-631-3574 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Enumeration Date | 2007-06-12 |
| Last Update Date | 2012-08-27 |