Basic Information
| Provider Information | |||||||||
| NPI: | 1174045124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISMA HEALTH MEDICAL GROUP-MIDLANDS | ||||||||
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| OtherOrganizationName: | PH MEDICAL GROUP MIDLANDS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22265 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032965928 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK RD STE L9L10 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346812 | ||||||||
| FaxNumber: | 8034347306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR-PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8643854790 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7660520006 | 01 | SC | DME MEDICARE PTAN | OTHER | DE3873 | 01 | SC | DME MEDICAID | OTHER | GP8162 | 05 | SC | MEDICAID |