Provider Demographics
NPI:1659316743
Name:PALMETTO HEALTH
Entity Type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:NORTHEAST FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE DIRECTOR OF BUSINESS DEV.
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:COVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-296-7301
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7313
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3000 NE MEDICAL PARK
Practice Address - Street 2:SUITE 209
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6251
Practice Address - Country:US
Practice Address - Phone:803-736-6262
Practice Address - Fax:803-699-1934
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0039Medicaid
SC7654Medicare PIN