Provider Demographics
NPI:1952453847
Name:PALMETTO GENERAL SURGERY
Entity Type:Organization
Organization Name:PALMETTO GENERAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:FIEDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-764-0754
Mailing Address - Street 1:9213 C UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-764-0754
Mailing Address - Fax:843-572-2653
Practice Address - Street 1:9213 C UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-764-0754
Practice Address - Fax:843-572-2653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC126768Medicaid
SC126768Medicaid
SC2965Medicare PIN