Basic Information
| Provider Information | |||||||||
| NPI: | 1114299575 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMETTO HEALTH | ||||||||
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| OtherOrganizationName: | COLUMBIA GASTROENTEROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 2739 LAUREL ST | ||||||||
| Address2: | SUITE 1-A | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037994800 | ||||||||
| FaxNumber: | 8032560397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2012 | ||||||||
| LastUpdateDate: | 04/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | COVEN | ||||||||
| AuthorizedOfficialFirstName: | DARRELL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR-AMBULATORY SERVICES-FINANC | ||||||||
| AuthorizedOfficialTelephone: | 8032967301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PALMETTO HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | GP5853 | 05 | SC | MEDICAID |