Healthcare Provider Details

I. General information

NPI: 1760963243
Provider Name (Legal Business Name): PRISMA HEALTH-UPSTATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 JOHN ST STE 104
EASLEY SC
29640-1405
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 864-855-0344
  • Fax: 864-859-6927
Mailing address:
  • Phone: 864-455-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: POLLY H. MILLER
Title or Position: SVP FINANCE, ENTERPRISE CONTRACTING
Credential:
Phone: 864-522-2286