Provider Demographics
NPI:1841291127
Name:PALMETTO ORTHOPAEDIC CLINIC, PA
Entity type:Organization
Organization Name:PALMETTO ORTHOPAEDIC CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONSTABLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-699-5540
Mailing Address - Street 1:105 OFFICE PARK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-5959
Mailing Address - Country:US
Mailing Address - Phone:803-699-5540
Mailing Address - Fax:803-699-5547
Practice Address - Street 1:105 OFFICE PARK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5959
Practice Address - Country:US
Practice Address - Phone:803-699-5540
Practice Address - Fax:803-699-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
SC5804207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3996Medicaid
SC6210810001Medicare NSC
SCC61328Medicare UPIN
SCGP3996Medicaid