Provider Demographics
NPI:1083137871
Name:RURAL PODIATRY, LLC
Entity Type:Organization
Organization Name:RURAL PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:434-250-4862
Mailing Address - Street 1:7010 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:VA
Mailing Address - Zip Code:24558-2392
Mailing Address - Country:US
Mailing Address - Phone:434-250-4862
Mailing Address - Fax:
Practice Address - Street 1:7010 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:HALIFAX
Practice Address - State:VA
Practice Address - Zip Code:24558-2392
Practice Address - Country:US
Practice Address - Phone:434-250-4862
Practice Address - Fax:727-803-6980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVV14519855213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067202Medicaid