Provider Demographics
NPI:1629014188
Name:PALMETTO HEALTH ALLIANCE
Entity Type:Organization
Organization Name:PALMETTO HEALTH ALLIANCE
Other - Org Name:PALMETTO WOMEN'S WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE DIRECTOR OF BUSINESS DEV.
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:COVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-296-7304
Mailing Address - Street 1:1 RICHLAND MEDICAL PARK
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6834
Mailing Address - Country:US
Mailing Address - Phone:803-434-2490
Mailing Address - Fax:
Practice Address - Street 1:1 RICHLAND MEDICAL PARK
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6834
Practice Address - Country:US
Practice Address - Phone:803-434-2490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-22
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3664Medicaid
SCGP3664Medicaid