Provider Demographics
NPI:1578548616
Name:ROELS, PHILIP M (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:M
Last Name:ROELS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 TROON DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-8846
Mailing Address - Country:US
Mailing Address - Phone:704-737-0685
Mailing Address - Fax:
Practice Address - Street 1:1601 BRENNER AVE
Practice Address - Street 2:EYE CLINIC (11I)
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2515
Practice Address - Country:US
Practice Address - Phone:704-638-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1937152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093R1OtherBCBS NC
NC89093R1Medicaid
NC7833605OtherAETNA
NC2471646Medicare ID - Type Unspecified
V02108Medicare UPIN
NCP00233957Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE