1699894113 NPI number — MISS HARRIET ANNETTE ROSE MASTER OF ART

Table of content: DR. SCOTT DAVID GOODROAD D.O. (NPI 1578764205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699894113 NPI number — MISS HARRIET ANNETTE ROSE MASTER OF ART

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSE
Provider First Name:
HARRIET
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MASTER OF ART
Provider Gender Code:
F

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:
1699894113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 E CHEVES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29506-2526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-317-4089
Provider Business Mailing Address Fax Number:
843-317-4096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
675 N MATTHEWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29560-7027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-394-7600
Provider Business Practice Location Address Fax Number:
843-661-4892
Provider Enumeration Date:
03/28/2007

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: 101YS0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 376241 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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