1073506002 NPI number — CARILION MEDICAL CENTER

Table of content: (NPI 1073506002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073506002 NPI number — CARILION MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARILION MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073506002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 S JEFFERSON ST STE 1006
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24011-1713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-224-5715
Provider Business Mailing Address Fax Number:
540-224-5684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1615 FRANKLIN RD SW
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24016-5208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-224-4800
Provider Business Practice Location Address Fax Number:
540-982-5785
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GRISETTI
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONAL SUPPORT
Authorized Official Telephone Number:
540-224-5352

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  EXEMPT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4972589 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002166 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 08061400032 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 30488 . This is a "PARTNERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 497258 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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