Provider Demographics
NPI:1679974588
Name:PALMETTO SPINE & PAIN CARE CONSULTANTS, LLC
Entity Type:Organization
Organization Name:PALMETTO SPINE & PAIN CARE CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOATWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-798-9686
Mailing Address - Street 1:3926 WESLEY ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-7332
Mailing Address - Country:US
Mailing Address - Phone:843-353-1596
Mailing Address - Fax:843-236-5088
Practice Address - Street 1:4736 HIGHWAY 17 BYP S
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-5616
Practice Address - Country:US
Practice Address - Phone:843-213-2039
Practice Address - Fax:843-293-2454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6742Medicaid
SCGP6742Medicaid