Basic Information
| Provider Information | |||||||||
| NPI: | 1588712103 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO ANESTHESIA SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9263 MEDICAL PLAZA DR | ||||||||
| Address2: | STE E | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294067112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435537070 | ||||||||
| FaxNumber: | 8435532223 | ||||||||
| Practice Location | |||||||||
| Address1: | 5039 BARRIER ISLAND CT | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294666933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438810403 | ||||||||
| FaxNumber: | 8435532223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 07/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | PRATT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8435537070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | DG4590 | 01 | SC | RAILROAD MEDICARE | OTHER | GP4685 | 05 | SC | MEDICAID |