Provider Demographics
NPI:1205840956
Name:CARILION MEDICAL CENTER
Entity Type:Organization
Organization Name:CARILION MEDICAL CENTER
Other - Org Name:CARILION DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONAL SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-224-5352
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:2017 JEFFERSON ST SW
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2419
Practice Address - Country:US
Practice Address - Phone:540-981-7128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARILION MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01619Medicare Oscar/Certification
VACI3613Medicare PIN
VAC06774Medicare Oscar/Certification