MEDICARE: PALMETTO HEALTH UNIVERSITY OF SOUTH CAROLINA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053817320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO HEALTH UNIVERSITY OF SOUTH CAROLINA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 743904
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3904
Country	:	US
Telephone Number	:	803-296-7320
Fax Number	:	803-296-7330

Provider Business Practice Location Address
First Line	:	3600 FOREST DR FL 3
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4052
Country	:	US
Telephone Number	:	803-749-5101
Fax Number	:	803-933-3045

Authorized Official
Title or Position	:	CHIEF MEDICAL OFFICER
Name	:	WILLIAM D. ANDERSON III,
Credential	:	MD
Telephone Number	:	803-545-5005

Provider Enumeration Date	:	04/04/2018
Last Update Date	:	04/04/2018

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