Basic Information
| Provider Information | |||||||||
| NPI: | 1194837849 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO SURGICAL ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 TAYLOR ST | ||||||||
| Address2: | STE 3A | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032544707 | ||||||||
| FaxNumber: | 8032541198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 TAYLOR ST | ||||||||
| Address2: | STE 3A | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032544707 | ||||||||
| FaxNumber: | 8032541198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 01/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | METROPOL | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8032544707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | PA0873 | 05 | SC | MEDICAID |