Healthcare Provider Details

I. General information

NPI: 1538657267
Provider Name (Legal Business Name): PALMETTO HEALTH - UNIVERSITY OF SOUTH CAROLINA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 RICHLAND MEDICAL PARK DR STE 320
COLUMBIA SC
29203-6896
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-8721
  • Fax: 803-434-3955
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM D. ANDERSON III,
Title or Position: CHIEF MEDICAL OFFICER
Credential:
Phone: 803-545-5005