Healthcare Provider Details

I. General information

NPI: 1073318069
Provider Name (Legal Business Name): PALMETTO PODIATRY GROUP OF ANDERSON, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BEN CASEY DR
FORT MILL SC
29708-8561
US

IV. Provider business mailing address

PO BOX 825159
PHILADELPHIA PA
19182-5159
US

V. Phone/Fax

Practice location:
  • Phone: 803-396-8670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: KIYA BOYCE
Title or Position: REGIONAL CREDENTIALING SPECIALIST
Credential:
Phone: 704-897-2261