Healthcare Provider Details

I. General information

NPI: 1134512395
Provider Name (Legal Business Name): PRISMA HEALTH-UPSTATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S BROAD ST
CLINTON SC
29325-2505
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-0973
  • Fax: 864-833-9571
Mailing address:
  • Phone: 864-455-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: POLLY H. MILLER
Title or Position: VP PAYOR STRATEGIES & ALIGNMENT
Credential:
Phone: 864-522-2286