Provider Demographics
NPI:1558320275
Name:PALMETTO PEDIATRIC GASTROENTEROLOGY
Entity Type:Organization
Organization Name:PALMETTO PEDIATRIC GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RATHNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:AMARNATH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:803-254-1006
Mailing Address - Street 1:2113 ADAMS GRV
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-7102
Mailing Address - Country:US
Mailing Address - Phone:803-254-1006
Mailing Address - Fax:803-254-2090
Practice Address - Street 1:2113 ADAMS GRV
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7102
Practice Address - Country:US
Practice Address - Phone:803-254-1006
Practice Address - Fax:803-254-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14383261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3080Medicaid
SC=========OtherEIN #
SCGP3080Medicaid