Basic Information
| Provider Information | |||||||||
| NPI: | 1114031564 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRISMA HEALTH-MIDLANDS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRISMA HEALTH PRIVATE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7275 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292027275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032963100 | ||||||||
| FaxNumber: | 8032963319 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 PICKENS ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292013465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032963100 | ||||||||
| FaxNumber: | 8032963319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | VP PAYOR STRATEGIES ALIGNMENT | ||||||||
| AuthorizedOfficialTelephone: | 8645222286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRISMA HEALTH-MIDLANDS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | Y | Agencies | Voluntary or Charitable |
ID Information
| ID | Type | State | Issuer | Description | MC0014 | 05 | SC | MEDICAID | EX0691 | 05 | SC | MEDICAID |