Provider Demographics
NPI:1831318856
Name:GREENWOOD GENETICS CENTER, INC.
Entity Type:Organization
Organization Name:GREENWOOD GENETICS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-941-8100
Mailing Address - Street 1:101 GREGOR MENDEL CIR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2316
Mailing Address - Country:US
Mailing Address - Phone:864-388-1072
Mailing Address - Fax:864-388-1052
Practice Address - Street 1:14 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4246
Practice Address - Country:US
Practice Address - Phone:864-250-7944
Practice Address - Fax:864-250-9582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC170100000X
207SG0201X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA2005Medicaid
SCPA2005Medicaid