1184663007 NPI number — PALMETTO PRIMARY CARE PHYSICIANS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184663007 NPI number — PALMETTO PRIMARY CARE PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO PRIMARY CARE PHYSICIANS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184663007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 530062
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30353-0062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-695-6071
Provider Business Mailing Address Fax Number:
843-569-5881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 EXECUTIVE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONCKS CORNER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29461-3955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-761-2815
Provider Business Practice Location Address Fax Number:
843-899-4723
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ARNAU
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
BRANTLEY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
843-572-7727

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP2858 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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