Basic Information
| Provider Information | |||||||||
| NPI: | 1245650381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENVILLE HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GHS CENTER FOR PEDIATRIC MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976400 | ||||||||
| FaxNumber: | 8647976198 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 MEDICAL RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642207270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/05/2015 | ||||||||
| NPIReactivationDate: | 01/15/2015 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIORDAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8647977808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HTL343 | SC | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 354643 | 05 | SC | MEDICAID | CI4624 | 01 | SC | MEDICARE RAILROAD | OTHER | 400783 | 05 | SC | MEDICAID | 42D0665869 | 01 | SC | CLIA | OTHER | GP2859 | 05 | SC | MEDICAID | 6510325 | 01 | SC | AETNA ID | OTHER | CB9553 | 01 | SC | MEDICARE RAILROAD | OTHER | CD7464 | 01 | SC | MEDICARE RAILROAD | OTHER | 111717 | 05 | SC | MEDICAID |