Provider Demographics
NPI:1124335898
Name:PALMETTO INTERNAL MEDICINE & PRIMARY CARE, PA
Entity type:Organization
Organization Name:PALMETTO INTERNAL MEDICINE & PRIMARY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BALA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNIAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-991-9015
Mailing Address - Street 1:300 W BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2538
Mailing Address - Country:US
Mailing Address - Phone:864-277-8300
Mailing Address - Fax:864-288-8722
Practice Address - Street 1:300 W BUTLER RD
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2538
Practice Address - Country:US
Practice Address - Phone:864-277-8300
Practice Address - Fax:864-288-8722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG61634Medicare UPIN