Provider Demographics
NPI:1346343563
Name:CARDIOTHORACIC SURGEONS OF ROANOKE VALLEY LLC
Entity Type:Organization
Organization Name:CARDIOTHORACIC SURGEONS OF ROANOKE VALLEY LLC
Other - Org Name:CARDIOTHORACIC SURGEONS OF ROANOKE VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:BUDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-772-3527
Mailing Address - Street 1:1802 BRAEBURN DR
Mailing Address - Street 2:SUITE 1310
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-776-2029
Mailing Address - Fax:540-776-2017
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:SUITE 1310
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-776-2029
Practice Address - Fax:540-776-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346343563Medicaid
VA1346343563Medicaid
DF6322Medicare PIN