Basic Information
| Provider Information | |||||||||
| NPI: | 1285678078 | ||||||||
| 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 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967032 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 RICHLAND MEDICAL PARK DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034347995 | ||||||||
| FaxNumber: | 8034347983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF INTEGRATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8035455048 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | OPAC03 | 05 | SC | MEDICAID |