Provider Demographics
NPI:1558340786
Name:PALMETTO FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:PALMETTO FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:803-934-0810
Mailing Address - Street 1:115 N SUMTER ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4972
Mailing Address - Country:US
Mailing Address - Phone:803-934-0810
Mailing Address - Fax:803-934-0809
Practice Address - Street 1:115 N SUMTER ST
Practice Address - Street 2:SUITE 315
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4972
Practice Address - Country:US
Practice Address - Phone:803-934-0810
Practice Address - Fax:803-934-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3552Medicaid
SC=========OtherTAX IDENTIFICATION NUMBER
SC=========OtherTAX IDENTIFICATION NUMBER