Basic Information
| Provider Information | |||||||||
| NPI: | 1134102718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITAKER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 CLEMSON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292294341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037886146 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Practice Location | |||||||||
| Address1: | 7941 BROAD RIVER RD | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290632358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032521816 | ||||||||
| FaxNumber: | 8032529132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 18808 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 188086 | 05 | SC | MEDICAID |