Provider Demographics
NPI:1558307116
Name:ROANOKE MEDICAL CENTER
Entity Type:Organization
Organization Name:ROANOKE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VENABLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-793-4500
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NC
Mailing Address - Zip Code:27962-1026
Mailing Address - Country:US
Mailing Address - Phone:252-793-4500
Mailing Address - Fax:252-793-2079
Practice Address - Street 1:1004 HWY 64 EAST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962
Practice Address - Country:US
Practice Address - Phone:252-793-4500
Practice Address - Fax:252-793-2079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22192208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-0271FMedicaid
NC0271FOtherBCBS
NCC85479Medicare UPIN
NC2317443Medicare ID - Type Unspecified