Provider Demographics
NPI:1578890273
Name:PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Entity Type:Organization
Organization Name:PRISMA HEALTH UNIVERSITY MEDICAL GROUP
Other - Org Name:PH DEVELOPMENTAL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PROVIDER ENROLLMENT & CVO
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:864-522-8611
Mailing Address - Street 1:7 INDEPENDENCE PT STE 140
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4550
Mailing Address - Country:US
Mailing Address - Phone:864-385-4790
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-5115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDRC010Medicaid
SCDEC300Medicaid
SC20032744OtherSELECT HEALTH ID NUMBER