Basic Information
Provider Information | |||||||||
NPI: | 1508322959 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROPER HOSPITAL, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ROPER HEART FAILURE CLINIC | ||||||||
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: | 8437891620 | ||||||||
FaxNumber: | 8437242454 | ||||||||
Practice Location | |||||||||
Address1: | 316 CALHOUN ST | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294011113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437205665 | ||||||||
FaxNumber: | 8437242852 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2019 | ||||||||
LastUpdateDate: | 04/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8437242954 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | GP8910 | 05 | SC |   | MEDICAID |