Provider Demographics
NPI:1922023738
Name:PALMETTO OXYGEN, LLC
Entity type:Organization
Organization Name:PALMETTO OXYGEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSALESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-246-9499
Mailing Address - Street 1:555 E NORTH LN STE 5075
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2233
Mailing Address - Country:US
Mailing Address - Phone:215-388-1719
Mailing Address - Fax:
Practice Address - Street 1:4790 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-8126
Practice Address - Country:US
Practice Address - Phone:803-228-7402
Practice Address - Fax:839-274-5811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC65008058332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1828Medicaid
SC3942920001Medicare ID - Type UnspecifiedPROVIDER NUMBER
SC3942920001Medicare NSC