Healthcare Provider Details

I. General information

NPI: 1720533474
Provider Name (Legal Business Name): PRISMA HEALTH-UPSTATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LILA DOYLE DR
SENECA SC
29672-9495
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 864-885-7678
  • Fax:
Mailing address:
  • Phone: 864-455-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCF-0990
License Number StateSC

VIII. Authorized Official

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