Provider Demographics
NPI:1477723724
Name:PALMETTO PODIATRY GROUP OF ANDERSON, PA
Entity Type:Organization
Organization Name:PALMETTO PODIATRY GROUP OF ANDERSON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:864-231-6395
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29716-0337
Mailing Address - Country:US
Mailing Address - Phone:803-396-8670
Mailing Address - Fax:803-396-8657
Practice Address - Street 1:105 BEN CASEY DR
Practice Address - Street 2:SUITE 133
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8561
Practice Address - Country:US
Practice Address - Phone:803-396-8670
Practice Address - Fax:803-396-8657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC534213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9957Medicaid
SC7192Medicare PIN
SCGP9957Medicaid
SC4740790002Medicare NSC