Provider Demographics
NPI:1467629261
Name:PALMETTO MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:PALMETTO MEDICAL GROUP, PLLC
Other - Org Name:PALMETTO MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIT
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-548-7007
Mailing Address - Street 1:1040 EDGEWATER CORPORATE PKWY SUITE 101
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7177
Mailing Address - Country:US
Mailing Address - Phone:803-548-7007
Mailing Address - Fax:
Practice Address - Street 1:1040 EDGEWATER CORPORATE PKWY SUITE 101
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-7177
Practice Address - Country:US
Practice Address - Phone:803-548-7007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO MEDICAL GROUP, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9074Medicare PIN