Provider Demographics
NPI:1275715690
Name:THERIOT ROLEY, LAURIE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:MARIE
Last Name:THERIOT ROLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:M
Other - Last Name:THERIOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:255 ENTERPRISE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6300
Practice Address - Country:US
Practice Address - Phone:864-454-8120
Practice Address - Fax:864-454-8125
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34100207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC341008Medicaid
SC341008Medicaid