Provider Demographics
NPI:1457361669
Name:PALMETTO PEDIATRIC
Entity Type:Organization
Organization Name:PALMETTO PEDIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-788-6146
Mailing Address - Street 1:74 POLO RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-2806
Mailing Address - Country:US
Mailing Address - Phone:803-788-6146
Mailing Address - Fax:803-462-0312
Practice Address - Street 1:74 POLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-2806
Practice Address - Country:US
Practice Address - Phone:803-788-6146
Practice Address - Fax:803-462-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0803Medicaid