Basic Information
| Provider Information | |||||||||
| NPI: | 1942775952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROPER SAINT FRANCIS PHYSICIANS NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROPER ST FRANCIS PHYSICIAN PARTNERS UROLOGY | ||||||||
| 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: | 300 CALLEN BLVD STE 220 | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294862809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438848045 | ||||||||
| FaxNumber: | 8438815081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2018 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | OLIVERIO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8437899319 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | GP8744 | 05 | SC | MEDICAID |