Provider Demographics
NPI:1407301302
Name:PRISMA HEALTH-UPSTATE
Entity type:Organization
Organization Name:PRISMA HEALTH-UPSTATE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP FIN-ENTERPRISE PAYOR CONTRACTIN
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-522-2286
Mailing Address - Street 1:300 E MCBEE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 STONEY POINT DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4628
Practice Address - Country:US
Practice Address - Phone:864-522-1950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-20
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCH4053OtherCMS PACE PROGRAM
SCEX1649Medicaid