Healthcare Provider Details

I. General information

NPI: 1518406784
Provider Name (Legal Business Name): PALMETTO AXON NEUROMONITORING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1643 B SAVANNAH HWY #304
CHARLESTON SC
29407-2202
US

IV. Provider business mailing address

1643 B SAVANNAH HWY #304
CHARLESTON SC
29407-2202
US

V. Phone/Fax

Practice location:
  • Phone: 843-872-9623
  • Fax:
Mailing address:
  • Phone: 843-872-9623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DON STOVALL JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 843-872-9623