Basic Information
| Provider Information | |||||||||
| NPI: | 1922051143 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISMA HEALTH-MIDLANDS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRISMA HEALTH EMERGENCY PHYSICIANS BAPTIST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1330 TALYOR AT MARION STREETS | ||||||||
| Address2: | 1ST FLOOR SUITE 100 | ||||||||
| City: | COULMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032962525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | VP PAYOR STRATEGIES ALIGNMENT | ||||||||
| AuthorizedOfficialTelephone: | 8645222286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP3930 | 05 | SC | MEDICAID |