Basic Information
| Provider Information | |||||||||
| NPI: | 1295222503 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISMA HEALTH MEDICAL GROUP-MIDLANDS | ||||||||
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| OtherOrganizationName: | PH ORAL & MAXILLOFACIAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 3304 FOREST DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292044024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346565 | ||||||||
| FaxNumber: | 8034346299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2018 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8647976118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZA8923 | 05 | SC | MEDICAID |