Basic Information
| Provider Information | |||||||||
| NPI: | 1760967053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO PRIMARY CARE PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530062 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303530062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436956071 | ||||||||
| FaxNumber: | 8435695881 | ||||||||
| Practice Location | |||||||||
| Address1: | 14866 OCEAN HWY | ||||||||
| Address2: | |||||||||
| City: | PAWLEYS ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295854801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432350760 | ||||||||
| FaxNumber: | 8434920177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8436956071 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | GP8909 | 05 | SC | MEDICAID |