Provider Demographics
NPI:1740572205
Name:ETHAN B. COLLIVER D.O. PLLC
Entity Type:Organization
Organization Name:ETHAN B. COLLIVER D.O. PLLC
Other - Org Name:COLLIVER SPORTS AND SPINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:COLLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:540-345-3556
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-777-1147
Practice Address - Street 1:3706 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7006
Practice Address - Country:US
Practice Address - Phone:540-345-3556
Practice Address - Fax:540-777-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202537208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty