1447257712 NPI number — DR. THOMAS M ROESCH MD

Table of content: DR. THOMAS M ROESCH MD (NPI 1447257712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447257712 NPI number — DR. THOMAS M ROESCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROESCH
Provider First Name:
THOMAS
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447257712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
313 WATER MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29650-3628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-979-3802
Provider Business Mailing Address Fax Number:
888-630-6942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 WATER MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29650-3628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-979-3802
Provider Business Practice Location Address Fax Number:
800-630-6942
Provider Enumeration Date:
07/01/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  14872 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 14872 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 35.135295 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 148726 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".