Healthcare Provider Details

I. General information

NPI: 1508897109
Provider Name (Legal Business Name): PALMETTO PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 INDIA HOOK RD SUITE A
ROCK HILL SC
29732-3270
US

IV. Provider business mailing address

PO BOX 60099
CHARLOTTE NC
28260-0099
US

V. Phone/Fax

Practice location:
  • Phone: 803-327-5772
  • Fax: 803-327-9303
Mailing address:
  • Phone: 803-327-5772
  • Fax: 803-327-9303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL L. WIENS
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-355-0648