Basic Information
| Provider Information | |||||||||
| NPI: | 1205414828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRISMA HEALTH-UPSTATE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRISMA HEALTH PRIMARY CARE FOUNTAIN INN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 N. NELSON DRIVE | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN INN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645226270 | ||||||||
| FaxNumber: | 8645226275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2021 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, PAYOR STRATEGIES & ALIGNMENT | ||||||||
| AuthorizedOfficialTelephone: | 8645222286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.