Provider Demographics
NPI:1598790115
Name:SOUTH ROANOKE OB-GYN PC
Entity Type:Organization
Organization Name:SOUTH ROANOKE OB-GYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:W
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-345-3556
Mailing Address - Street 1:PO BOX 8478
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0478
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:2110 CAROLINA AVE SW
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1702
Practice Address - Country:US
Practice Address - Phone:540-345-3556
Practice Address - Fax:540-342-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237419207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADD7281OtherRAILROAD MEDICARE
VA179613OtherANTHEM
VAG94324Medicare UPIN
VADD7281OtherRAILROAD MEDICARE
VAI36612Medicare UPIN
VAI37132Medicare UPIN