1578890273 NPI number — PRISMA HEALTH UNIVERSITY MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578890273 NPI number — PRISMA HEALTH UNIVERSITY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578890273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 INDEPENDENCE PT STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-385-4790
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PATEWOOD DR
Provider Second Line Business Practice Location Address:
SUITE A200
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-3593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-454-5115
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LAWRENCE
Authorized Official First Name:
KRISTI
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
DIRECTOR PROVIDER ENROLLMENT & CVO
Authorized Official Telephone Number:
864-522-8611

Provider Taxonomy Codes

  • Taxonomy code: 2080P0006X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DRC010 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DEC300 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20032744 . This is a "SELECT HEALTH ID NUMBER" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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