Provider Demographics
NPI:1790079960
Name:PALMETTO MEDICAL GROUP, LLP
Entity Type:Organization
Organization Name:PALMETTO MEDICAL GROUP, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SERJE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-499-6099
Mailing Address - Street 1:337 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2738
Mailing Address - Country:US
Mailing Address - Phone:718-499-6099
Mailing Address - Fax:718-499-6391
Practice Address - Street 1:337 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2738
Practice Address - Country:US
Practice Address - Phone:718-499-6099
Practice Address - Fax:718-499-6391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179466207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty