Provider Demographics
NPI:1316134828
Name:WALTER W ROGAN
Entity type:Organization
Organization Name:WALTER W ROGAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROGAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:843-426-2170
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:105 S. MAIN ST.
Mailing Address - City:GREELEYVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29056-0277
Mailing Address - Country:US
Mailing Address - Phone:843-426-2170
Mailing Address - Fax:843-426-2166
Practice Address - Street 1:215 VARNER AVE
Practice Address - Street 2:
Practice Address - City:GREELEYVILLE
Practice Address - State:SC
Practice Address - Zip Code:29056-0000
Practice Address - Country:US
Practice Address - Phone:843-426-2170
Practice Address - Fax:843-426-2166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC617023332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC617023Medicaid
SC1172110001Medicare NSC