Basic Information
| Provider Information | |||||||||
| NPI: | 1023428745 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMETTO PRIMARY CARE PHYSICIANS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. GEORGE FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530062 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303530062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435636000 | ||||||||
| FaxNumber: | 8435695881 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 RIDGE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT GEORGE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294772446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435636000 | ||||||||
| FaxNumber: | 8435636015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2014 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARNAU | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | BRANTLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8425727727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP6503 | 05 | SC | MEDICAID |