Basic Information
| Provider Information | |||||||||
| NPI: | 1558340786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO FAMILY PRACTICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 N SUMTER ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039340810 | ||||||||
| FaxNumber: | 8039340809 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 N SUMTER ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039340810 | ||||||||
| FaxNumber: | 8039340809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | FLEMING | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | RUSSELL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8039340810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP3552 | 05 | SC | MEDICAID |