Provider Demographics
NPI: | 1538139795 |
---|---|
Name: | PALMETTO PATHOLOGY PA |
Entity Type: | Organization |
Organization Name: | PALMETTO PATHOLOGY PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT PALMETTO PATHOLOGY PA |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ALEXANDER |
Authorized Official - Middle Name: | C |
Authorized Official - Last Name: | LOGAN |
Authorized Official - Suffix: | III |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 843-716-7000 |
Mailing Address - Street 1: | PO BOX 60070 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29419-0070 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-716-7000 |
Mailing Address - Fax: | 843-716-7272 |
Practice Address - Street 1: | 3655 MITCHELL ST |
Practice Address - Street 2: | DEPARTMENT OF PATHOLOGY |
Practice Address - City: | LORIS |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29569-2827 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-716-7000 |
Practice Address - Fax: | 843-716-7272 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-01-23 |
Last Update Date: | 2008-08-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Single Specialty |
No | 207ZB0001X | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | Group - Single Specialty |
No | 207ZC0500X | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | Group - Single Specialty |
No | 207ZD0900X | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | Group - Single Specialty |
No | 207ZF0201X | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology | Group - Single Specialty |
No | 207ZH0000X | Allopathic & Osteopathic Physicians | Pathology | Hematology | Group - Single Specialty |
No | 207ZI0100X | Allopathic & Osteopathic Physicians | Pathology | Immunopathology | Group - Single Specialty |
No | 207ZM0300X | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | Group - Single Specialty |
No | 207ZN0500X | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | Group - Single Specialty |
No | 207ZP0007X | Allopathic & Osteopathic Physicians | Pathology | Molecular Genetic Pathology | Group - Single Specialty |
No | 207ZP0101X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | Group - Single Specialty |
No | 207ZP0104X | Allopathic & Osteopathic Physicians | Pathology | Chemical Pathology | Group - Single Specialty |
No | 207ZP0105X | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | Group - Single Specialty |
No | 207ZP0213X | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SC | GP2307 | Medicaid | |
NC | 790285N | Medicaid | |
SC | GP2307 | Medicaid | |
SC | 6112 | Medicare PIN | |
NC | 790285N | Medicaid |