1013944206 NPI number — PALMETTO VASCULAR DIAGNOSTIC LLC

Table of content: (NPI 1013944206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013944206 NPI number — PALMETTO VASCULAR DIAGNOSTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO VASCULAR DIAGNOSTIC 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:
1013944206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 MCQUEEN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGEBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29118-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-308-1524
Provider Business Mailing Address Fax Number:
803-937-6520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 MCQUEEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29118-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-308-1524
Provider Business Practice Location Address Fax Number:
803-937-6520
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-308-1524

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2471V0105X , with the licence number: 33630 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: SL0071 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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