Healthcare Provider Details

I. General information

NPI: 1174045124
Provider Name (Legal Business Name): PRISMA HEALTH MEDICAL GROUP-MIDLANDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK RD STE L9L10
COLUMBIA SC
29203-6808
US

IV. Provider business mailing address

PO BOX 22265
BELFAST ME
04915-4473
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6812
  • Fax: 803-434-7306
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTI LAWRENCE
Title or Position: DIRECTOR-PROVIDER ENROLLMENT
Credential:
Phone: 864-385-4790