Provider Demographics
NPI:1265462659
Name:PALMETTO INFUSION SERVICES LLC
Entity Type:Organization
Organization Name:PALMETTO INFUSION SERVICES LLC
Other - Org Name:PALMETTO INFUSION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-227-5447
Mailing Address - Street 1:PO BOX 538476
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8476
Mailing Address - Country:US
Mailing Address - Phone:803-227-5447
Mailing Address - Fax:
Practice Address - Street 1:3105 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3425
Practice Address - Country:US
Practice Address - Phone:800-809-1265
Practice Address - Fax:803-772-7782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QI0500X, 332B00000X
SC115123336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1489Medicaid
SCIC0015Medicaid
SCIC0018Medicaid
SCIC0021Medicaid
SCIC0017Medicaid
SCIC0025Medicaid
SCIC0014Medicaid
SCIC0020Medicaid
SC711512Medicaid
SCIC0024Medicaid
SCIC0026Medicaid
SCIC0016Medicaid
SCIC0023Medicaid
SCIC0022Medicaid
SC771357Medicaid
SCIC0019Medicaid
SCIC0027Medicaid
SCIC0019Medicaid
SC6999Medicare PIN