Basic Information
| Provider Information | |||||||||
| NPI: | 1982791414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADER | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RADER | ||||||||
| OtherFirstName: | ANN-MARIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | SAINT STEPHEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294790280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435674000 | ||||||||
| FaxNumber: | 8435673000 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | SAINT STEPHEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294793371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435674000 | ||||||||
| FaxNumber: | 8435673000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1147 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0458PA | 05 | SC | MEDICAID |