1558442079 NPI number — PALMETTO HEALTH

Table of content: (NPI 1083424758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558442079 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:
1558442079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 402145
Provider Second Line Business Mailing Address:
PALMETTO HEALTH
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-2145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-2548
Provider Business Mailing Address Fax Number:
803-296-3040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 RICHLAND MEDICAL PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE310
Provider Business Practice Location Address City Name:
COULMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-296-2548
Provider Business Practice Location Address Fax Number:
803-296-2548
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ECKERT
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DIRECTOR OF PFS
Authorized Official Telephone Number:
803-296-2548

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , 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: GP1795 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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