Basic Information
Provider Information | |||||||||
NPI: | 1275857369 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROPER SAINT FRANCIS PHYSICIANS NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PALMETTO PODIATRY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 751649 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282751649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437891651 | ||||||||
FaxNumber: | 8437242653 | ||||||||
Practice Location | |||||||||
Address1: | 3510 HIGHWAY 17 N | ||||||||
Address2: | SUITE 110 | ||||||||
City: | MT PLEASANT | ||||||||
State: | SC | ||||||||
PostalCode: | 294668227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438849159 | ||||||||
FaxNumber: | 8439711105 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2010 | ||||||||
LastUpdateDate: | 10/15/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOWLING | ||||||||
AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP RSFPN | ||||||||
AuthorizedOfficialTelephone: | 8437242903 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 131 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
ID | Type | State | Issuer | Description | DP0704 | 01 | SC | RAILROAD MEDICARE GROUP PTAN | OTHER | GP9893 | 05 | SC |   | MEDICAID |