Provider Demographics
NPI:1285678078
Name:PRISMA HEALTH MEDICAL GROUP-MIDLANDS
Entity Type:Organization
Organization Name:PRISMA HEALTH MEDICAL GROUP-MIDLANDS
Other - Org Name:PH MEDICAL GROUP MIDLANDS
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF INTEGRATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-545-5048
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7032
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 410
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-7995
Practice Address - Fax:803-434-7983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCOPAC03Medicaid