Provider Demographics
NPI:1386628071
Name:BOATWRIGHT, ROGER DALE (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:BOATWRIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:864-522-8611
Mailing Address - Fax:
Practice Address - Street 1:704 N A ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2142
Practice Address - Country:US
Practice Address - Phone:864-859-4480
Practice Address - Fax:864-859-3750
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22401207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL31794Medicaid
SCL31794Medicaid
SCH393659372Medicare PIN
SCH393657589Medicare PIN
SCH393658065Medicare PIN