Basic Information
| Provider Information | |||||||||
| NPI: | 1457361669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO PEDIATRIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74 POLO RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292232806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037886146 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Practice Location | |||||||||
| Address1: | 74 POLO RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292232806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037886146 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HART | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8037886146 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | GP0803 | 05 | SC | MEDICAID |