MEDICARE: PALMETTO RADIOLOGY, PA

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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1548333768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO RADIOLOGY, PA

Provider Business Mailing Address
First Line	:	PO BOX 388
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29116-0388
Country	:	US
Telephone Number	:	803-534-0053
Fax Number	:	803-536-1198

Provider Business Practice Location Address
First Line	:	901 W GREENWOOD ST
Second Line	:
City	:	ABBEVILLE
State	:	SC
Zip	:	29620-5678
Country	:	US
Telephone Number	:	803-534-0053
Fax Number	:	803-536-1198

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RANDY GRAHAM
Credential	:	MD
Telephone Number	:	803-534-0053

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	08/22/2020

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