Provider Demographics
NPI:1851642458
Name:PALMETTO HEALTH
Entity Type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:PARKRIDGE MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, AMBULATORY SERVICES, FIN.
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:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:100 PALMETTO HEALTH PARKWAY
Practice Address - Street 2:SUITE 220
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1755
Practice Address - Country:US
Practice Address - Phone:803-749-0693
Practice Address - Fax:803-749-3986
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-24
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6103Medicaid
SCC126Medicare PIN