Basic Information
| Provider Information | |||||||||
| NPI: | 1225130891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918 | ||||||||
| Address2: | 1035 CHERAW ST. | ||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295120918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434540841 | ||||||||
| FaxNumber: | 8434540635 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 COMMERCE AVE. | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297090000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436232229 | ||||||||
| FaxNumber: | 8436232553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 05/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 12005 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208D00000X | 12005 | NC | N | Allopathic & Osteopathic Physicians | General Practice | 2084P0800X | 4007 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 69225 | 01 | NC | BCBS | OTHER | 477030 | 01 | NC | HUMANA GOLD CHOICE | OTHER | 5906238 | 05 | NC | MEDICAID | AP0343676 | 01 | NC | DEA | OTHER |