Basic Information
Provider Information | |||||||||
NPI: | 1497342471 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRISMA HEALTH-MIDLANDS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PH FAMILY MEDICINE-BISHOPVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 E MCBEE AVE FL 4 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296012842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644557000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 116 HOSPITAL SQ | ||||||||
Address2: |   | ||||||||
City: | BISHOPVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 290107081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8034849424 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/24/2020 | ||||||||
LastUpdateDate: | 12/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | POLLY | ||||||||
AuthorizedOfficialMiddleName: | H. | ||||||||
AuthorizedOfficialTitleorPosition: | SVP FINANCE, ENTERPRISE CONTRACTING | ||||||||
AuthorizedOfficialTelephone: | 8645222286 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.