Provider Demographics
NPI:1942266176
Name:PALMETTO SPINE & SPORTS MEDICINE, PA
Entity Type:Organization
Organization Name:PALMETTO SPINE & SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ZGLESZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-573-9997
Mailing Address - Street 1:3030 ASHLEY TOWN CENTER DR
Mailing Address - Street 2:BLGD A-102
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5664
Mailing Address - Country:US
Mailing Address - Phone:843-573-9997
Mailing Address - Fax:843-377-1446
Practice Address - Street 1:3030 ASHLEY TOWN CENTER DR
Practice Address - Street 2:BLGD A-102
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5664
Practice Address - Country:US
Practice Address - Phone:843-573-9997
Practice Address - Fax:843-377-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3855Medicaid
SCGP3855Medicaid