Provider Demographics
NPI:1336311901
Name:PALMETTO HEALTH
Entity Type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:BAPTIST VASCULAR LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, AMBULATORY SVCS - FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:COVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-296-7301
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:TAYLOR AT MARION ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29220-0001
Practice Address - Country:US
Practice Address - Phone:803-296-5162
Practice Address - Fax:803-296-5594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-24
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4875Medicaid
SCGP4875Medicaid