Provider Demographics
NPI:1831128586
Name:PALMETTO HEALTH
Entity Type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:PEDIATRIC HEMATOLOGY/ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR - BUSINESS DEV/FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:COVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-296-7301
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7306
Mailing Address - Fax:803-296-7329
Practice Address - Street 1:7 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 203
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6863
Practice Address - Country:US
Practice Address - Phone:803-434-3533
Practice Address - Fax:803-434-3094
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-02
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4175Medicaid
SCGP4175Medicaid