Provider Demographics
NPI:1871550251
Name:PALMETTO GASTROENTEROLOGY, PA
Entity type:Organization
Organization Name:PALMETTO GASTROENTEROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:803-799-2219
Mailing Address - Street 1:2750 LAUREL ST
Mailing Address - Street 2:STE 201
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-799-2219
Mailing Address - Fax:803-933-0725
Practice Address - Street 1:2750 LAUREL ST
Practice Address - Street 2:STE 201
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-799-2219
Practice Address - Fax:803-933-0725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0932Medicaid
SCGP0932Medicaid