Provider Demographics
NPI:1104150739
Name:ROPER HOSPITAL, INC.
Entity type:Organization
Organization Name:ROPER HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-724-2954
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2454
Practice Address - Street 1:1481 TOBIAS GADSON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4794
Practice Address - Country:US
Practice Address - Phone:843-402-3093
Practice Address - Fax:843-402-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC083OtherBCBS SC AND BLUECHOICE SUFIX
SCGP5274Medicaid
SC088/093OtherTRICARE SUFFIX
SCGP5274Medicaid