Provider Demographics
NPI:1275169807
Name:PALMETTO OBGYN LLC
Entity Type:Organization
Organization Name:PALMETTO OBGYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:OLUBUNMI
Authorized Official - Middle Name:ASHABI
Authorized Official - Last Name:ALO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-353-2111
Mailing Address - Street 1:PO BOX 51827
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0031
Mailing Address - Country:US
Mailing Address - Phone:843-353-2111
Mailing Address - Fax:843-628-4326
Practice Address - Street 1:3864 RENEE DRIVE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:843-353-2111
Practice Address - Fax:843-628-4326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9634Medicaid