Basic Information
| Provider Information | |||||||||
| NPI: | 1144710641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO HEALTH - UNIVERSITY OF SOUTH CAROLINA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 RICHLAND MEDICAL PARK DRIVE | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034343822 | ||||||||
| FaxNumber: | 8034343821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2018 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON III, | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8035455005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GP7530 | 05 | SC | MEDICAID |