Healthcare Provider Details

I. General information

NPI: 1225480486
Provider Name (Legal Business Name): PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 FRONTAGE RD SUITE 1
CLEMSON SC
29631-1691
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-654-6034
  • Fax:
Mailing address:
  • Phone: 864-385-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierGP7326
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: KRISTI ANN LAWRENCE
Title or Position: DIRECTOR PROVIDER ENROLLMENT
Credential:
Phone: 864-797-6118