Healthcare Provider Details

I. General information

NPI: 1447749510
Provider Name (Legal Business Name): PRISMA HEALTH MEDICAL GROUP-MIDLANDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N SUMTER ST STE 115
SUMTER SC
29150-4968
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-774-7546
  • Fax: 803-774-9735
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number StateSC

VIII. Authorized Official

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