Provider Demographics
NPI:1568476711
Name:HAINES, PETER C (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:HAINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:300 PALMETTO HEALTH PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1761
Practice Address - Country:US
Practice Address - Phone:803-907-7100
Practice Address - Fax:803-907-7109
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13063208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570926300OtherTAX I.D. NUMBER
SCTL5189Medicaid