Basic Information
| Provider Information | |||||||||
| NPI: | 1851508089 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMETTO HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PALMETTO HEALTHY START | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 223 STONERIDGE DRIVE, SUITE B | ||||||||
| Address2: | PALMETTO HEALTHY START | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032962548 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 STONERIDGE DRIVE, SUITE B | ||||||||
| Address2: | PALMETTO HEALTHY START | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032962548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ECKERT | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PFS | ||||||||
| AuthorizedOfficialTelephone: | 8032962548 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | SC | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | MC0017 | 05 | SC | MEDICAID |