Healthcare Provider Details

I. General information

NPI: 1467440644
Provider Name (Legal Business Name): PALMETTO ADULT AND CHILDRENS UROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2890 TRICOM ST
NORTH CHARLESTON SC
29406-9171
US

IV. Provider business mailing address

2890 TRICOM ST
NORTH CHARLESTON SC
29406-9171
US

V. Phone/Fax

Practice location:
  • Phone: 843-797-6600
  • Fax: 843-820-1440
Mailing address:
  • Phone: 843-797-6600
  • Fax: 843-820-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMELIA MUNKBERG
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 843-797-6600