Provider Demographics
NPI:1760158208
Name:ROANOKE PEDIATRICS PLLC
Entity Type:Organization
Organization Name:ROANOKE PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:540-613-8565
Mailing Address - Street 1:1901 DENNISTON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2023
Mailing Address - Country:US
Mailing Address - Phone:540-613-8565
Mailing Address - Fax:
Practice Address - Street 1:1901 DENNISTON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2023
Practice Address - Country:US
Practice Address - Phone:540-613-8565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty