Healthcare Provider Details

I. General information

NPI: 1578890273
Provider Name (Legal Business Name): PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE A200
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

7 INDEPENDENCE PT STE 140
GREENVILLE SC
29615-4550
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-5115
  • Fax:
Mailing address:
  • Phone: 864-385-4790
  • Fax:

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: KRISTI ANN LAWRENCE
Title or Position: DIRECTOR PROVIDER ENROLLMENT & CVO
Credential:
Phone: 864-522-8611