Healthcare Provider Details

I. General information

NPI: 1841291127
Provider Name (Legal Business Name): PALMETTO ORTHOPAEDIC CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 OFFICE PARK RD
COLUMBIA SC
29223-5959
US

IV. Provider business mailing address

105 OFFICE PARK RD
COLUMBIA SC
29223-5959
US

V. Phone/Fax

Practice location:
  • Phone: 803-699-5540
  • Fax: 803-699-5547
Mailing address:
  • Phone: 803-699-5540
  • Fax: 803-699-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5804
License Number StateSC

VIII. Authorized Official

Name: DR. DEANNA L CONSTABLE
Title or Position: PRESIDENT
Credential: MD
Phone: 803-699-5540