Provider Demographics
NPI:1467691568
Name:PALMETTO TRAVEL MEDICINE
Entity Type:Organization
Organization Name:PALMETTO TRAVEL MEDICINE
Other - Org Name:PASSPORT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:NIELSEN
Authorized Official - Last Name:BREWSTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:843-225-5688
Mailing Address - Street 1:2154 N CENTER ST
Mailing Address - Street 2:SUITE A-104
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-4056
Mailing Address - Country:US
Mailing Address - Phone:843-225-5688
Mailing Address - Fax:843-225-5689
Practice Address - Street 1:2154 N CENTER ST
Practice Address - Street 2:SUITE A-104
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4056
Practice Address - Country:US
Practice Address - Phone:843-225-5688
Practice Address - Fax:843-225-5689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR98024174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty