Provider Demographics
NPI:1861560765
Name:PALMETTO PEDIATRICS, PA
Entity type:Organization
Organization Name:PALMETTO PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHODNICKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-797-5600
Mailing Address - Street 1:2781 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9170
Mailing Address - Country:US
Mailing Address - Phone:843-797-5600
Mailing Address - Fax:
Practice Address - Street 1:2781 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9170
Practice Address - Country:US
Practice Address - Phone:843-797-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0233Medicaid