Healthcare Provider Details

I. General information

NPI: 1881604114
Provider Name (Legal Business Name): PALMETTO ORTHOPAEDIC AND SPORTS MEDICINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W WESMARK BLVD
SUMTER SC
29150-1969
US

IV. Provider business mailing address

595 W WESMARK BLVD
SUMTER SC
29150-1969
US

V. Phone/Fax

Practice location:
  • Phone: 803-469-4028
  • Fax: 803-469-2663
Mailing address:
  • Phone: 803-469-4028
  • Fax: 803-469-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number4919
License Number StateSC

VIII. Authorized Official

Name: KAROLINE K KIRVEN
Title or Position: OFFICE MANGER
Credential: DO
Phone: 803-469-4028