Provider Demographics
NPI:1508855727
Name:JEREMIAH, MICHAEL PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:JEREMIAH
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 1:5628 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3848
Mailing Address - Country:US
Mailing Address - Phone:540-776-9575
Mailing Address - Fax:
Practice Address - Street 1:2145 MOUNT PLEASANT BLVD SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-3632
Practice Address - Country:US
Practice Address - Phone:540-427-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5615313Medicaid
VA080102543OtherMEDICARE RAILROAD
VA5635179Medicaid
VA080102543OtherMEDICARE RAILROAD
VAF77308Medicare UPIN