Basic Information
Provider Information | |||||||||
NPI: | 1013041367 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PALMETTO HEATLH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PALMETTO HEALTH COULMBIA CRNA SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 744244 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303744244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032962548 | ||||||||
FaxNumber: | 8032962548 | ||||||||
Practice Location | |||||||||
Address1: | 3301 HARDEN ST EXT 5 MEDICAL PARK | ||||||||
Address2: | PALMETTO HEALTH CRNA RICHLAND | ||||||||
City: | COULMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292036813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032962548 | ||||||||
FaxNumber: | 8032962548 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2007 | ||||||||
LastUpdateDate: | 10/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | WILLIE | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT ACCOUNTS | ||||||||
AuthorizedOfficialTelephone: | 8032962342 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PALMETTO HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   | SC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | SUFFIX 008 | 01 | SC | BCBS CRNA RICHLAND | OTHER |