Healthcare Provider Details

I. General information

NPI: 1013244714
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: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE A200
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 864-454-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State

VIII. Authorized Official

Name: POLLY MILLER
Title or Position: SVP-FIN ENTERPRISE PAYOR CONTRACTIN
Credential:
Phone: 864-522-2286