Provider Demographics
NPI:1184634156
Name:CARILION PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:CARILION PROFESSIONAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-224-5715
Mailing Address - Street 1:213 S JEFFERSON ST
Mailing Address - Street 2:SUITE 801
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1705
Mailing Address - Country:US
Mailing Address - Phone:540-224-5125
Mailing Address - Fax:540-985-4948
Practice Address - Street 1:213 S JEFFERSON ST
Practice Address - Street 2:SUITE 801
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24011-1705
Practice Address - Country:US
Practice Address - Phone:540-224-5125
Practice Address - Fax:540-985-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACH9983Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP #
VAC06937Medicare ID - Type UnspecifiedMEDICARE SUFFIX GROUP ID