Healthcare Provider Details

I. General information

NPI: 1275169807
Provider Name (Legal Business Name): PALMETTO OBGYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 10/16/2020
Certification Date: 08/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3864 RENEE DRIVE
MYRTLE BEACH SC
29579
US

IV. Provider business mailing address

PO BOX 51827
MYRTLE BEACH SC
29579-0031
US

V. Phone/Fax

Practice location:
  • Phone: 843-353-2111
  • Fax: 843-628-4326
Mailing address:
  • Phone: 843-353-2111
  • Fax: 843-628-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierGP9634
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: OLUBUNMI ASHABI ALO
Title or Position: MD
Credential: MD
Phone: 843-353-2111