Healthcare Provider Details

I. General information

NPI: 1922596535
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: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RICHLAND MEDICAL PARK DR
COLUMBIA SC
29203-6863
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4506
  • Fax: 803-434-4852
Mailing address:
  • Phone: 803-296-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry 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