Healthcare Provider Details

I. General information

NPI: 1255094694
Provider Name (Legal Business Name): ROBERT SOUTH EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UNIVERSITY RDG
GREENVILLE SC
29601-3635
US

IV. Provider business mailing address

108 OLD RUTHERFORD RD
TAYLORS SC
29687-5735
US

V. Phone/Fax

Practice location:
  • Phone: 864-282-4100
  • Fax:
Mailing address:
  • Phone: 706-466-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberSC036492
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: