Healthcare Provider Details

I. General information

NPI: 1265527097
Provider Name (Legal Business Name): PALMETTO HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 STONERIDGE DR
COLUMBIA SC
29210-8009
US

IV. Provider business mailing address

PO BOX 1669
COLUMBIA SC
29202-1669
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-5990
  • Fax: 803-296-2400
Mailing address:
  • Phone: 803-254-2394
  • Fax: 803-254-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BERNICE K RICHARDSON
Title or Position: MEDICAL AFFAIRS MANAGER
Credential:
Phone: 803-254-2394