Basic Information
| Provider Information | |||||||||
| NPI: | 1659615268 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROPER SAINT FRANCIS PHYSICIANS NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CLINIC AT BISHOP GADSDEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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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: | 1 BISHOP GADSDEN WAY | ||||||||
| Address2: | SUITE 97 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434062362 | ||||||||
| FaxNumber: | 8436068082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2012 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLIVERIO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CEO RSFPP | ||||||||
| AuthorizedOfficialTelephone: | 8437242903 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 182 | 01 | SC | BCBS SC AND BLUECHOICE SUFFIX | OTHER | GP6086 | 05 | SC | MEDICAID |