Provider Demographics
NPI:1225480486
Name:PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Entity Type:Organization
Organization Name:PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Other - Org Name:CLEMSON-SENECA PEDIATRICS-CLEMSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-797-6118
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-385-4790
Mailing Address - Fax:
Practice Address - Street 1:208 FRONTAGE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1691
Practice Address - Country:US
Practice Address - Phone:864-654-6034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7326Medicaid