Healthcare Provider Details

I. General information

NPI: 1295788354
Provider Name (Legal Business Name): PALMETTO PODIATRY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 HENDERSON STREET SUITE B
COLUMBIA SC
29201
US

IV. Provider business mailing address

1730 HENDERSON STREET SUITE B
COLUMBIA SC
29201
US

V. Phone/Fax

Practice location:
  • Phone: 803-376-1717
  • Fax: 803-376-1716
Mailing address:
  • Phone: 803-376-1717
  • Fax: 803-376-1716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00151
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number00151
License Number StateSC

VIII. Authorized Official

Name: DR. JOSEPH J MORAN
Title or Position: OWNER
Credential: DPM
Phone: 803-376-1717