Basic Information
| Provider Information | |||||||||
| NPI: | 1659660645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO PRIMARY CARE PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53062 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303551062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436956071 | ||||||||
| FaxNumber: | 8435695881 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ELMS CENTER RD | ||||||||
| Address2: | |||||||||
| City: | N CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435727727 | ||||||||
| FaxNumber: | 8435695881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | ARNAU | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | BRANTLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8435727727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | GP5897 | 05 | SC | MEDICAID | DPE089 | 05 | SC | MEDICAID |