Provider Demographics
NPI:1700374436
Name:PALMETTO HEALTH - UNIVERSITY OF SOUTH CAROLINA MEDICAL GROUP
Entity Type:Organization
Organization Name:PALMETTO HEALTH - UNIVERSITY OF SOUTH CAROLINA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON III,
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-545-5005
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:2 MEDICAL PARK RD STE 302
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-545-5800
Practice Address - Fax:803-907-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7530Medicaid