Provider Demographics
NPI:1073750816
Name:ROANOKE IMAGING LLC
Entity Type:Organization
Organization Name:ROANOKE IMAGING LLC
Other - Org Name:LEWIS GALE IMAGING AT BRAMBLETON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:4330 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3405
Mailing Address - Country:US
Mailing Address - Phone:540-688-6763
Mailing Address - Fax:540-283-3701
Practice Address - Street 1:4330 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3405
Practice Address - Country:US
Practice Address - Phone:540-688-6763
Practice Address - Fax:540-283-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073750816Medicaid
VA1073750816OtherBCBS
VA1073750816Medicaid