1265462659 NPI number — PALMETTO INFUSION SERVICES LLC

Table of content: (NPI 1265462659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265462659 NPI number — PALMETTO INFUSION SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO INFUSION SERVICES 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:
PALMETTO INFUSION SERVICES
Provider Other Organization Name Type Code:
3
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:
1265462659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 538476
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:
30353-8476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-227-5447
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3105 SUNSET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-809-1265
Provider Business Practice Location Address Fax Number:
803-772-7782
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARTLEY
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VICE PRESIDENT REIMBURSEMENT
Authorized Official Telephone Number:
803-227-5447

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 11512 , 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: DE1489 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0015 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0018 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0021 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0017 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0025 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0014 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0020 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 711512 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0024 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0026 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0016 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0023 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0022 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 771357 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0019 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: IC0027 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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