Basic Information
| Provider Information | |||||||||
| NPI: | 1104150739 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROPER HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE RYAN WHITE WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242454 | ||||||||
| Practice Location | |||||||||
| Address1: | 1481 TOBIAS GADSON BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434023093 | ||||||||
| FaxNumber: | 8434023094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2009 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8437242954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 083 | 01 | SC | BCBS SC AND BLUECHOICE SUFIX | OTHER | 088/093 | 01 | SC | TRICARE SUFFIX | OTHER | GP5274 | 05 | SC | MEDICAID |