Provider Demographics
NPI:1457433278
Name:PALMETTO DERMATOLOGY
Entity type:Organization
Organization Name:PALMETTO DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-796-2500
Mailing Address - Street 1:3574 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3044
Mailing Address - Country:US
Mailing Address - Phone:803-796-2500
Mailing Address - Fax:803-796-4378
Practice Address - Street 1:3574 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3044
Practice Address - Country:US
Practice Address - Phone:803-796-2500
Practice Address - Fax:803-796-4378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA1426Medicaid
SCPA1426Medicaid