Provider Demographics
NPI:1962471946
Name:PALMETTO HEALTH
Entity Type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:PALMETTO HEALTH SENIOR PRIMARY CARE PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-434-1210
Mailing Address - Street 1:3010 FARROW RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-7607
Mailing Address - Country:US
Mailing Address - Phone:803-434-1210
Mailing Address - Fax:803-434-1212
Practice Address - Street 1:3010 FARROW RD
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7607
Practice Address - Country:US
Practice Address - Phone:803-434-1210
Practice Address - Fax:803-434-1212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-14
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207RG0300X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1537Medicaid
SCGP1537Medicaid
SC420018Medicare Oscar/Certification