Healthcare Provider Details

I. General information

NPI: 1225101173
Provider Name (Legal Business Name): PALMETTO RADIOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22725 HIGHWAY 76E
CLINTON SC
29325
US

IV. Provider business mailing address

PO BOX 388
ORANGEBURG SC
29116-0388
US

V. Phone/Fax

Practice location:
  • Phone: 803-534-0053
  • Fax: 803-536-1198
Mailing address:
  • Phone: 803-534-0053
  • Fax: 803-536-1198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDY GRAHAM
Title or Position: PRESIDENT
Credential: MD
Phone: 803-534-0053