Basic Information
Provider Information | |||||||||
NPI: | 1548331176 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PALMER | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | OTIS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6439 GARNERS FERRY RD | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292091638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037764000 | ||||||||
FaxNumber: | 8037764000 | ||||||||
Practice Location | |||||||||
Address1: | 6439 GARNERS FERRY RD | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292091638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037764000 | ||||||||
FaxNumber: | 8037764000 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2006 | ||||||||
LastUpdateDate: | 08/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 22842 | AL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 58257864831902-B001 | 01 |   | TRICARE | OTHER | 93425 | 01 | GA | BCBS | OTHER | 582578648PAL1 | 01 |   | ENERGREEN | OTHER | 152306631 | 01 |   | TRICARE | OTHER | 60016721 | 01 | AL | BCBS | OTHER | 9900705 | 01 | AL | CAID | OTHER | 00495129F | 05 | GA |   | MEDICAID |