Basic Information
| Provider Information | |||||||||
| NPI: | 1881059053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO CENTER FOR MEDICAL WEIGHT LOSS AND PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100523 | ||||||||
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| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295020523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 412 N GUM ST | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294836830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438731720 | ||||||||
| FaxNumber: | 8438731108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2015 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8438731720 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | GP7143 | 05 | SC | MEDICAID |