Basic Information
| Provider Information | |||||||||
| NPI: | 1306396585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034342762 | ||||||||
| FaxNumber: | 8034342713 | ||||||||
| 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: | 10/11/2016 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | APRIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8034341842 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | 20438 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery | 207RA0001X | 20438 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | 207RA0201X | 20438 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207RC0000X | 20438 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208G00000X | 20438 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 20000290 | 01 | SC | FIRST CHOICE SELECT UB | OTHER | 20000321 | 01 | SC | FIRST CHOICE SELECT 1500 | OTHER | 400186 | 05 | SC | MEDICAID |