Basic Information
| Provider Information | |||||||||
| NPI: | 1679974588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO SPINE & PAIN CARE CONSULTANTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3926 WESLEY ST | ||||||||
| Address2: | SUITE 502 | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295797332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433531596 | ||||||||
| FaxNumber: | 8432365088 | ||||||||
| Practice Location | |||||||||
| Address1: | 4736 HIGHWAY 17 BYP S | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295885616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432132039 | ||||||||
| FaxNumber: | 8432932454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 08/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | BOATWRIGHT | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8437989686 | ||||||||
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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 | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP6742 | 05 | SC | MEDICAID |