Provider Demographics
NPI:1669415915
Name:PALMETTO HEALTH
Entity type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, AMBULATORY SVCS - FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:COVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-296-7301
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 320
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6877
Practice Address - Country:US
Practice Address - Phone:803-434-6771
Practice Address - Fax:803-434-3955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-14
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3676Medicaid
SCGP3676Medicaid