Provider Demographics
NPI:1578660775
Name:NORTH ROANOKE REHAB MED PC
Entity Type:Organization
Organization Name:NORTH ROANOKE REHAB MED PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AE-SIK
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-265-6710
Mailing Address - Street 1:PO BOX 4127
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-0127
Mailing Address - Country:US
Mailing Address - Phone:540-344-9781
Mailing Address - Fax:540-344-7154
Practice Address - Street 1:5720 WILLIAMSON RD
Practice Address - Street 2:SUITE 107
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1225
Practice Address - Country:US
Practice Address - Phone:540-265-6710
Practice Address - Fax:540-265-6712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C08947Medicare PIN