NPIMap

Organization Active NPI

Upstate Affiliate Organization

  • Developmental Disabilities Clinic/Center
  • Spartanburg, SC
National Provider Identifier
1831639459
Registry record updated Mar 1, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Developmental Disabilities Clinic/CenterTaxonomy code 261QD1600X
License
HTL-0936 Issued in SC
Legal business name
UPSTATE AFFILIATE ORGANIZATION
Practice address
249 N Grove Medical Park Dr
#300
Spartanburg, SC 29303-4227
Phone
(864) 598-0420
Fax
(864) 598-0431
NPI assigned
Mar 1, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 1, 2017

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

Authorized official

Name
Spence M Taylor, MD
Title
Executive - Corporate
Phone
(864) 797-6118

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Developmental Disabilities Clinic/Center 261QD1600X HTL-0936 SC Primary

Addresses

Primary practice location

249 N Grove Medical Park Dr
#300
Spartanburg, SC 29303-4227

Mailing address

1 Independence PT
Suite 212
Greenville, SC 29615-4545
Phone (864) 797-6307

Other names 1

  • GHS Kidnetics - Spartanburg Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20161118000626 SC Part A Provider - Hospital 5698063162 38 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Hospital certification: CCN 420078

Legal name
PRISMA HEALTH-UPSTATE
Doing business as
PRISMA HEALTH PEDIATRICS VERDAE
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Nov 6, 1972
Last certification
Jun 12, 2015
Beds
845
Ownership / control type
Private (not for profit)
Most recent change of ownership
Oct 1, 2016 (1 total)
Organization structure
OtherNon-profit
Incorporated
Apr 1, 2019 in SC
Enrollment address
701 Grove Rd
Greenville, SC 29605-4210
Main/Primary Hospital Location
Hospital subgroups
General, Acute care

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

Other NPIs on the same Medicare enrollment 38

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 38

Care Compare: Hospital

Medicare Care Compare
Listed as
Prisma Health Greenville Memorial HospitalCCN 420078
Overall star rating
4 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
No

National Provider Directory

National Provider Directory

Locations

249 North Grove Medical Park Dr
Ste 300
Spartanburg, SC 29303
Phone (864) 598-0420

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 Corporate OfficerSVP Finance, Enterprise Contracting Mar 20, 2020 100%
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 Created for acquisition 5% Or Greater Direct Ownership Interest Oct 1, 2016 100%
Operational/Managerial Control Oct 1, 2016 100%

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 2,058

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 2,058

NPI Registry JSON

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

{
    "created_epoch": "1488326400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1488326400000",
    "number": "1831639459",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 INDEPENDENCE PT",
            "address_2": "SUITE 212",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296154545",
            "telephone_number": "864-797-6307"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "249 N GROVE MEDICAL PARK DR",
            "address_2": "#300",
            "city": "SPARTANBURG",
            "state": "SC",
            "postal_code": "293034227",
            "telephone_number": "864-598-0420",
            "fax_number": "864-598-0431"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UPSTATE AFFILIATE ORGANIZATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-03-01",
        "last_updated": "2017-03-01",
        "status": "A",
        "authorized_official_last_name": "TAYLOR",
        "authorized_official_first_name": "SPENCE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "EXECUTIVE - CORPORATE",
        "authorized_official_telephone_number": "864-797-6118",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QD1600X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Developmental Disabilities",
            "state": "SC",
            "license": "HTL-0936",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "GHS Kidnetics - Spartanburg",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Spartanburg, SC

Sources for this page

Verify at the official NPI Registry.