1366759839 NPI number — MRS. MOLLY SPEIGHT ROBERTS PA-C

Table of content: MRS. MOLLY SPEIGHT ROBERTS PA-C (NPI 1366759839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366759839 NPI number — MRS. MOLLY SPEIGHT ROBERTS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
MOLLY
Provider Middle Name:
SPEIGHT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPEIGHT
Provider Other First Name:
MOLLY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366759839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 ENTERPRISE BLVD
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-331-2505
Provider Business Mailing Address Fax Number:
864-331-2510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 ENTERPRISE BLVD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-331-2505
Provider Business Practice Location Address Fax Number:
864-331-2510
Provider Enumeration Date:
09/07/2010

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: 363A00000X , with the licence number:  C0005751 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0010-02457 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NCF4201298 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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