Provider Demographics
NPI:1477056794
Name:PALMETTO MOON ANESTHESIA, LLC
Entity type:Organization
Organization Name:PALMETTO MOON ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE/MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:843-861-3671
Mailing Address - Street 1:307 WINDING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:SC
Mailing Address - Zip Code:29030-8347
Mailing Address - Country:US
Mailing Address - Phone:843-861-3671
Mailing Address - Fax:803-490-1571
Practice Address - Street 1:3045 ST. MATTHEWS RD.
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118
Practice Address - Country:US
Practice Address - Phone:843-861-3671
Practice Address - Fax:803-490-1571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3877207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty