Provider Demographics
NPI:1922045103
Name:NETWORK GERIATRIC SERVICES, PA
Entity Type:Organization
Organization Name:NETWORK GERIATRIC SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:BRADFORD
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-327-1510
Mailing Address - Street 1:103 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1972
Mailing Address - Country:US
Mailing Address - Phone:864-327-1510
Mailing Address - Fax:864-327-1662
Practice Address - Street 1:103 S PINE ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1972
Practice Address - Country:US
Practice Address - Phone:864-327-1510
Practice Address - Fax:864-327-1662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12758207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4420Medicaid
SC8452Medicare PIN