Basic Information
| Provider Information | |||||||||
| NPI: | 1699252163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PS121 MANAGEMENT PA | ||||||||
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| OtherOrganizationName: | VIDA GYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 274 COMMONWEALTH DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647201299 | ||||||||
| FaxNumber: | 8647201300 | ||||||||
| Practice Location | |||||||||
| Address1: | 274 COMMONWEALTH DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647201299 | ||||||||
| FaxNumber: | 8647201300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2018 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | OOSTDYK | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | COORDINATOR, PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8647201299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.