=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992789473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROPER RADIOLOGISTS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2005
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 CALHOUN ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29401-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-724-2015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2363
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46206-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD - AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MATTHEW BRADY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 843-724-2015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------