Provider Demographics
NPI:1528397593
Name:PALMETTO PEDIATRICS
Entity Type:Organization
Organization Name:PALMETTO PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 601251
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1251
Mailing Address - Country:US
Mailing Address - Phone:803-327-5772
Mailing Address - Fax:803-327-9303
Practice Address - Street 1:9332 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3108
Practice Address - Country:US
Practice Address - Phone:803-327-5772
Practice Address - Fax:803-327-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB360Medicaid