Healthcare Provider Details

I. General information

NPI: 1851286645
Provider Name (Legal Business Name): PALMETTO FERTILITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 EXECUTIVE CENTER DR STE 300
GREENVILLE SC
29615-4555
US

IV. Provider business mailing address

700 EXECUTIVE CENTER DR STE 300
GREENVILLE SC
29615-4555
US

V. Phone/Fax

Practice location:
  • Phone: 864-412-1950
  • Fax: 864-412-0640
Mailing address:
  • Phone: 864-412-1950
  • Fax: 864-412-0640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE JEAN RAVECH
Title or Position: CHIEF MANAGED CARE OFFICER
Credential:
Phone: 860-305-6640