Provider Demographics
NPI:1518119023
Name:ROANOKE FAMILY PRACTICE
Entity Type:Organization
Organization Name:ROANOKE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-384-0154
Mailing Address - Street 1:902B ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-5565
Mailing Address - Country:US
Mailing Address - Phone:252-384-0154
Mailing Address - Fax:252-335-2731
Practice Address - Street 1:902B ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5565
Practice Address - Country:US
Practice Address - Phone:252-384-0154
Practice Address - Fax:252-335-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO2435OtherRAILROAD MEDICARE PIN
2193979JMedicare PIN