Provider Demographics
NPI:1467440644
Name:PALMETTO ADULT AND CHILDRENS UROLOGY PA
Entity Type:Organization
Organization Name:PALMETTO ADULT AND CHILDRENS UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNKBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-797-6600
Mailing Address - Street 1:2890 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9171
Mailing Address - Country:US
Mailing Address - Phone:843-797-6600
Mailing Address - Fax:843-820-1440
Practice Address - Street 1:2890 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9171
Practice Address - Country:US
Practice Address - Phone:843-797-6600
Practice Address - Fax:843-820-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4871Medicaid
SC7026OtherMEDICARE GROUP NUMBER