Healthcare Provider Details

I. General information

NPI: 1083787006
Provider Name (Legal Business Name): PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 VERDAE BLVD SUITE A
GREENVILLE SC
29607-4032
US

IV. Provider business mailing address

1025 VERDAE BLVD SUITE A
GREENVILLE SC
29607-4032
US

V. Phone/Fax

Practice location:
  • Phone: 864-242-4683
  • Fax: 864-240-8104
Mailing address:
  • Phone: 864-242-4683
  • Fax: 864-240-8104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateSC
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateSC

VIII. Authorized Official

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