Healthcare Provider Details

I. General information

NPI: 1790185494
Provider Name (Legal Business Name): PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE C300
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-8272
  • Fax:
Mailing address:
  • Phone: 864-385-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number626
License Number StateSC

VIII. Authorized Official

Name: KRISTI A LAWRENCE
Title or Position: DIRECTOR PROVIDER ENROLLMENT
Credential:
Phone: 864-797-6118