MEDICARE: PALMETTO SURGICAL CONSULTANTS ASSOCIATION,INC.

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	1223G0001X	General Practice Dentistry		SC

General Provider Information

NPI Number	:	1407101918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO SURGICAL CONSULTANTS ASSOCIATION,INC.

Provider Business Mailing Address
First Line	:	1330 GREGG ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3526
Country	:	US
Telephone Number	:	803-256-4304
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 GREGG ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3526
Country	:	US
Telephone Number	:	803-256-4304
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	DR. TRACE H RUTHERFORD
Credential	:	D.D.S.
Telephone Number	:	803-256-4304

Provider Enumeration Date	:	07/20/2012
Last Update Date	:	07/20/2012

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