Basic Information
| Provider Information | |||||||||
| NPI: | 1285860098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO VEIN SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9263 MEDICAL PLAZA DR | ||||||||
| Address2: | STE B | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294067112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435537070 | ||||||||
| FaxNumber: | 8435532223 | ||||||||
| Practice Location | |||||||||
| Address1: | 9313 MEDICAL PLAZA DR | ||||||||
| Address2: | STE 303 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438205372 | ||||||||
| FaxNumber: | 8438248359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2009 | ||||||||
| LastUpdateDate: | 12/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCCARDLE | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8438205372 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 6391 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | GP5265 | 05 | SC | MEDICAID |