Basic Information
| Provider Information | |||||||||
| NPI: | 1063569259 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISMA HEALTH-MIDLANDS | ||||||||
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| OtherOrganizationName: | PRISMA HEALTH OCCUPATIONAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PRISMA HEALTH OCCUPATIONAL MEDICINE | ||||||||
| Address2: | 300 E. MCBEE AVE FL 4 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
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| Practice Location | |||||||||
| Address1: | PRISMA HEALTH OCCUPATIONAL MEDICINE | ||||||||
| Address2: | 1333 TAYLOR STREETS SUITE 3-H | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292200001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1803296254 | ||||||||
| FaxNumber: | 1803296254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | VP PAYOR STRATEGIES ALIGNMENT | ||||||||
| AuthorizedOfficialTelephone: | 8645222286 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | SC | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 079 | 01 | SC | BCBS SUFIX | OTHER |