Provider Demographics
NPI:1326048380
Name:MELLENCAMP, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:MELLENCAMP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 BELLEVIEW AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1838
Mailing Address - Country:US
Mailing Address - Phone:540-981-7037
Mailing Address - Fax:540-342-1757
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040130E2085R0202X, 2085R0204X
DEC100063752085R0202X
DEC1-00063752085R0204X
VA01012430892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA502443L5QMedicare PIN
DE008315I36Medicare PIN
DEA56373Medicare UPIN