1477725463 NPI number — PALMETTO HEALTH

Table of content: ELENA BRAVERMAN MD (NPI 1194891705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477725463 NPI number — PALMETTO HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO HEALTH
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:
6
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:
1477725463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7275
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29202-7275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-3164
Provider Business Mailing Address Fax Number:
803-296-3319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
383 MCGEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAMBERG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29003-1338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-245-0390
Provider Business Practice Location Address Fax Number:
803-245-0083
Provider Enumeration Date:
03/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRIDGES
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
803-296-5678

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X , with the licence number:  056 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X , with the licence number: 056 , 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: HSP028 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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