Provider Demographics
NPI:1801852959
Name:PALMETTO UROLOGY PA
Entity Type:Organization
Organization Name:PALMETTO UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:V
Authorized Official - Last Name:BIRCHMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-534-5700
Mailing Address - Street 1:1747 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2475
Mailing Address - Country:US
Mailing Address - Phone:803-534-5700
Mailing Address - Fax:803-534-5712
Practice Address - Street 1:1747 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2475
Practice Address - Country:US
Practice Address - Phone:803-534-5700
Practice Address - Fax:803-534-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3595Medicaid
SCGP3595Medicaid