Basic Information
| Provider Information | |||||||||
| NPI: | 1053492280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISMA HEALTH-MIDLANDS | ||||||||
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| OtherOrganizationName: | DIABETES EDUCATIONS RICHLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PRISMA HEALTH DIABETES EDUCATION ATTN: KARLA K. POWELL | ||||||||
| Address2: | 300 E MCBEE AVE FL 4 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9 MEDICAL PARK SUITE 205 | ||||||||
| Address2: | PALMETTO HEALTH RICHLAND DIABETES EDUCATION | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032963040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | VP PAYOR STRATEGIES ALIGNMENT | ||||||||
| AuthorizedOfficialTelephone: | 8645222286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRISMA HEALTH-MIDLANDS | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | DEP012 | 01 | SC | INHANCE MEDICAID GRP | OTHER | 20029656 | 01 | SC | SELECT HEALTH GRP | OTHER |