Provider Demographics
NPI:1083830996
Name:VAN DER MEULEN, ROELOF A (DPT, ECS)
Entity Type:Individual
Prefix:DR
First Name:ROELOF
Middle Name:A
Last Name:VAN DER MEULEN
Suffix:
Gender:M
Credentials:DPT, ECS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 SIMONA RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-4535
Mailing Address - Country:US
Mailing Address - Phone:865-776-3757
Mailing Address - Fax:
Practice Address - Street 1:4701 SIMONA RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-4535
Practice Address - Country:US
Practice Address - Phone:865-776-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41752251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4175OtherSTATE LICENSE
TN3654099Medicaid
TN3717547OtherLEGACY GROUP
TN3650029Medicare PIN