Provider Demographics
NPI:1013914985
Name:ROANOKE AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:ROANOKE AMBULATORY SURGERY CENTER, LLC
Other - Org Name:ROANOKE AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-342-0707
Mailing Address - Street 1:1102 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4704
Mailing Address - Country:US
Mailing Address - Phone:540-342-5800
Mailing Address - Fax:
Practice Address - Street 1:1102 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4704
Practice Address - Country:US
Practice Address - Phone:540-342-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH636261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010053919Medicaid
VA125459800OtherDEPARTMENT OF LABOR ID NU
VA125459800OtherDEPARTMENT OF LABOR ID NU