1871080283 NPI number — PRISMA HEALTH MEDICAL GROUP-MIDLANDS

Table of content: (NPI 1871080283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871080283 NPI number — PRISMA HEALTH MEDICAL GROUP-MIDLANDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRISMA HEALTH MEDICAL GROUP-MIDLANDS
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:
PH MEDICAL GROUP MIDLANDS
Provider Other Organization Name Type Code:
5
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:
1871080283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-7320
Provider Business Mailing Address Fax Number:
803-296-7330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 N SUMTER ST STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-4971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-774-9425
Provider Business Practice Location Address Fax Number:
803-774-9796
Provider Enumeration Date:
04/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
LAWRENCE
Authorized Official First Name:
KRISTI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR PROVIDER ENROLLMENT
Authorized Official Telephone Number:
864-797-6118

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GP8575 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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