Healthcare Provider Details

I. General information

NPI: 1457848848
Provider Name (Legal Business Name): PRISMA HEALTH MEDICAL GROUP-MIDLANDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RICHLAND MEDICAL PARK DR STE 210
COLUMBIA SC
29203-6859
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-935-5604
  • Fax: 803-434-1920
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES ELLIS
Title or Position: CHIEF INTEGRATION OFFICER
Credential:
Phone: 803-545-5048