1790951267 NPI number — ON-SITE SPORTS MEDICINE SERVICES, INC.

Table of content: DR. DAVID MICHAEL FESAK DO (NPI 1790893832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790951267 NPI number — ON-SITE SPORTS MEDICINE SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ON-SITE SPORTS MEDICINE SERVICES, INC.
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:
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:
1790951267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21467
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:
24018-0555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
180-047-2064
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 HIGHLAND AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24016-4214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
180-047-2064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
TALENA
Authorized Official Middle Name:
COX
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
800-472-0646

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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