Basic Information
| Provider Information | |||||||||
| NPI: | 1730786096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISMA HEALTH UNIVERSITY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE STE 401 | ||||||||
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| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1519 MARION ST | ||||||||
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| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032965954 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2020 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8645228611 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRISMA HEALTH UNIVERSITY MEDICAL GROUP | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.