Provider Demographics
NPI:1760547848
Name:PALMETTO PODIATRY P.A.
Entity Type:Organization
Organization Name:PALMETTO PODIATRY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:843-881-9159
Mailing Address - Street 1:1220A HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3678
Mailing Address - Country:US
Mailing Address - Phone:843-881-9159
Mailing Address - Fax:843-971-1105
Practice Address - Street 1:1220A HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3251
Practice Address - Country:US
Practice Address - Phone:843-881-9159
Practice Address - Fax:843-971-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC990131213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD1313Medicaid
SCPD1313Medicaid
SC5285360001Medicare NSC
SCU48226Medicare PIN