Healthcare Provider Details

I. General information

NPI: 1013944206
Provider Name (Legal Business Name): PALMETTO VASCULAR DIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 MCQUEEN BLVD
ORANGEBURG SC
29118-1200
US

IV. Provider business mailing address

2020 MCQUEEN BLVD
ORANGEBURG SC
29118-1200
US

V. Phone/Fax

Practice location:
  • Phone: 803-308-1524
  • Fax: 803-937-6520
Mailing address:
  • Phone: 803-308-1524
  • Fax: 803-937-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number33630
License Number StateSC

VIII. Authorized Official

Name: ROBERT E MYERS
Title or Position: OWNER
Credential:
Phone: 803-308-1524