Provider Demographics
NPI:1013041367
Name:PALMETTO HEATLH
Entity Type:Organization
Organization Name:PALMETTO HEATLH
Other - Org Name:PALMETTO HEALTH COULMBIA CRNA SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-296-2342
Mailing Address - Street 1:PO BOX 744244
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4244
Mailing Address - Country:US
Mailing Address - Phone:803-296-2548
Mailing Address - Fax:803-296-2548
Practice Address - Street 1:3301 HARDEN ST EXT 5 MEDICAL PARK
Practice Address - Street 2:PALMETTO HEALTH CRNA RICHLAND
Practice Address - City:COULMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6813
Practice Address - Country:US
Practice Address - Phone:803-296-2548
Practice Address - Fax:803-296-2548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-16
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSUFFIX 008OtherBCBS CRNA RICHLAND