Basic Information
| Provider Information | |||||||||
| NPI: | 1083346258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO ASSISTED LIVING MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2029 | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287135029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287352822 | ||||||||
| FaxNumber: | 8285384549 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 CHINA COCKLE WAY | ||||||||
| Address2: | |||||||||
| City: | HILTON HEAD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299261907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287352822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2022 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | CASTOR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8287352822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5917260 | 05 | NC | MEDICAID |