Healthcare Provider Details

I. General information

NPI: 1275564007
Provider Name (Legal Business Name): PALMETTO HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 RICHARD ST
EASLEY SC
29640-1440
US

IV. Provider business mailing address

101 RICHARD ST
EASLEY SC
29640-1440
US

V. Phone/Fax

Practice location:
  • Phone: 864-859-4480
  • Fax: 864-859-3750
Mailing address:
  • Phone: 864-859-4480
  • Fax: 864-859-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierGP3686
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: BETH HENDERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 864-859-4480