Provider Demographics
NPI:1750767950
Name:PALMETTO HEALTH
Entity type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, BUS FINANCE
Authorized Official - Prefix:MR
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 848932
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8932
Mailing Address - Country:US
Mailing Address - Phone:803-296-7303
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:104 SALUDA POINTE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7295
Practice Address - Country:US
Practice Address - Phone:803-296-9200
Practice Address - Fax:803-296-9697
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-11
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207XS0106X, 207XX0004X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7495240002Medicare NSC