NPIMap

Organization Active NPI

Prisma Health-Upstate

Doing business as Prisma Health Primary Care Fountain Inn

  • Rural Health Clinic/Center
  • Fountain Inn, SC
National Provider Identifier
1205414828
Registry record updated Apr 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PRISMA HEALTH-UPSTATE
Doing business as
Prisma Health Primary Care Fountain Inn
Practice address
200 N. Nelson Drive
Fountain Inn, SC 29644
Phone
(864) 522-6270
Fax
(864) 522-6275
NPI assigned
Apr 2, 2021
Last updated
Apr 22, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 22, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Polly H. Miller
Title
VP, Payor Strategies & Alignment
Phone
(864) 522-2286

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

200 N. Nelson Drive
Fountain Inn, SC 29644

Mailing address

300 E McBee Ave FL 4
Greenville, SC 29601-2842
Phone (864) 522-8603

Other names 1

  • Prisma Health Primary Care Fountain Inn Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210422000284 SC Part A Provider - Rural Health Clinic 5698063162 Practice locations: Fountain Inn, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1205414828. Details of each certification follow.

Rural health clinic certification: CCN 423494

Legal name
PRISMA HEALTH-UPSTATE
Doing business as
PH PRIMARY CARE FOUNTAIN INN
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 1, 2022
Last certification
Feb 1, 2022
Ownership / control type
1B
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 2019 in SC
Enrollment address
200 N Nelson Dr
Fountain Inn, SC 29644-9021
Related CCNs
420037

Facilities connected through Provider of Services related, parent or unit certification numbers.

National Provider Directory

National Provider Directory
Tax ID family
Prisma Health-Upstate121 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Locations

200 N Nelson Dr
Fountain Inn, SC 29644
Phone (864) 522-6270

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kristi a Lawrence Individual Corporate DirectorDirector, Provider Enrollment & Cvo Apr 5, 2020 100%
W-2 Managing EmployeeDirector, Provider Enrollment & Cvo Apr 5, 2020 100%
Polly H Miller Individual 5% Or Greater Direct Ownership InterestSVP Finance, Enterprise Contracting Mar 20, 2020 5%
W-2 Managing EmployeeSVP Finance, Enterprise Contracting Mar 20, 2020 100%
Operational/Managerial ControlSVP Finance, Enterprise Contracting Mar 20, 2020 100%
Prisma Health-Upstate Organization, Greenville, SC 5% Or Greater Direct Ownership Interest Apr 1, 2019 100%

All facility ownership & control disclosures 26

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Prisma Health Hillcrest HospitalSimpsonville, SC, CCN 420037 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Greer Memorial HospitalGreer, SC, CCN 420033 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Marshall I PickensGreenville, SC, CCN 42S078 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Roger C Peace RehabilitationGreenville, SC, CCN 42T078 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Pediatrics VerdaeGreenville, SC, CCN 420078 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Oconee Memorial HospitalSeneca, SC, CCN 420009 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Laurens County HospitalClinton, SC, CCN 420038 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Oct 1, 2016
Oct 1, 2016
Prisma Health Patewood HospitalGreenville, SC, CCN 420102 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health North Greenville LtachTravelers Rest, SC, CCN 422008 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Baptist Easley Hospital O/P Therapy ServicesEasley, SC, CCN 420015 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2018
Oct 1, 2018
Prisma Health Home Health--UpstateGreenville, SC, CCN 427029 Home health agency 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Hospice of the FoothillsSeneca, SC, CCN 421508 Hospice 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Apr 1, 2019
Apr 1, 2019
PH Pediatrics-ClemsonClemson, SC, CCN 423455 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Laurens Family Med-MainLaurens, SC, CCN 423452 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2019
Apr 1, 2019
Prisma Health Laurens Family Med-Gray CTGray Court, SC, CCN 423454 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
PH Pediatrics-SenecaSeneca, SC, CCN 423456 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
Prisma Health Advanced Family MedicineClinton, SC, CCN 423458 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2016
Oct 1, 2016
PH Family Medicine-WalhallaWalhalla, SC, CCN 423475 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Seneca Medical AssociatesSeneca, SC, CCN 423474 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Mountain Lakes Family MedicineSeneca, SC, CCN 423476 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Family & Internal Medicine-SenecaSeneca, SC, CCN 423477 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Pediatrics-PowdersvilleGreenville, SC, CCN 423491 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Blue Ridge Women's CenterSeneca, SC, CCN 423490 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Premier Women's CareGreenville, SC, CCN 423498 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Primary Care North GreenvilleTravelers Rest, SC, CCN 423495 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019
PH Family Medicine-PowdersvilleGreenville, SC, CCN 428501 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2019

Facilities with the same owner 26

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1617321600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1650585600000",
    "number": "1205414828",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 E MCBEE AVE FL 4",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296012842",
            "telephone_number": "864-522-8603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 N. NELSON DRIVE",
            "city": "FOUNTAIN INN",
            "state": "SC",
            "postal_code": "29644",
            "telephone_number": "864-522-6270",
            "fax_number": "864-522-6275"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRISMA HEALTH-UPSTATE",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-04-02",
        "last_updated": "2022-04-22",
        "certification_date": "2022-04-22",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "POLLY",
        "authorized_official_middle_name": "H.",
        "authorized_official_title_or_position": "VP, PAYOR STRATEGIES & ALIGNMENT",
        "authorized_official_telephone_number": "864-522-2286"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Prisma Health Primary Care Fountain Inn",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Prisma Health Primary Care Fountain Inn",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fountain Inn, SC

Sources for this page

Verify at the official NPI Registry.