Basic Information
Provider Information | |||||||||
NPI: | 1942668074 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PALMETTO HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUMTER ORTHOPAEDIC SURGERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 402145 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303842145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032967303 | ||||||||
FaxNumber: | 8032967330 | ||||||||
Practice Location | |||||||||
Address1: | 100 N SUMTER ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291504975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037747621 | ||||||||
FaxNumber: | 8037741791 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2016 | ||||||||
LastUpdateDate: | 02/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COVEN | ||||||||
AuthorizedOfficialFirstName: | DARRELL | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, BUS FINANCE | ||||||||
AuthorizedOfficialTelephone: | 8032967301 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PALMETTO HEALTH | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.