Basic Information
| Provider Information | |||||||||
| NPI: | 1164066247 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROPER SAINT FRANCIS PHYSICIANS NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROPERST.FRANCIS PHYSICIANS PARTNERS PRIMARY CARE-DURST FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 STATION 22 1/2 ST | ||||||||
| Address2: | |||||||||
| City: | SULLIVANS ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294829756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438833176 | ||||||||
| FaxNumber: | 8438833459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | OLIVERIO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP AND CEO RSFPP | ||||||||
| AuthorizedOfficialTelephone: | 8437242903 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.