Basic Information
| Provider Information | |||||||||
| NPI: | 1033514120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402145 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967305 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034342762 | ||||||||
| FaxNumber: | 8034342713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2014 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | COVEN | ||||||||
| AuthorizedOfficialFirstName: | DARRELL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, AMBULATORY SRVCS FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8032967301 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PALMETTO HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | GP7115 | 05 | SC | MEDICAID |