Basic Information
| Provider Information | |||||||||
| NPI: | 1194214775 | ||||||||
| 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 DR STE 505 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034342505 | ||||||||
| FaxNumber: | 8034342181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2018 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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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 | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 133VN1004X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2080P0214X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | GP7530 | 05 | SC | MEDICAID |