Provider Demographics
NPI:1699252163
Name:PS121 MANAGEMENT PA
Entity type:Organization
Organization Name:PS121 MANAGEMENT PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-720-1299
Mailing Address - Street 1:330C PELHAM RD STE A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3111
Mailing Address - Country:US
Mailing Address - Phone:864-720-1299
Mailing Address - Fax:864-720-1300
Practice Address - Street 1:330C PELHAM RD STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3111
Practice Address - Country:US
Practice Address - Phone:864-720-1299
Practice Address - Fax:864-720-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty