Provider Demographics
NPI:1053396291
Name:PALMETTO FAMILY MEDICAL GROUP
Entity type:Organization
Organization Name:PALMETTO FAMILY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-847-1818
Mailing Address - Street 1:900 GREENVILLE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29697-1130
Mailing Address - Country:US
Mailing Address - Phone:864-847-1818
Mailing Address - Fax:864-847-5706
Practice Address - Street 1:900 GREENVILLE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-1130
Practice Address - Country:US
Practice Address - Phone:864-847-1818
Practice Address - Fax:864-847-5706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1600111N00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU29360Medicare UPIN