Provider Demographics
NPI:1184803330
Name:COLLIVER, ETHAN B (DO)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:B
Last Name:COLLIVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:120 PROFESSIONAL PARK DR SE STE 7
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6739
Mailing Address - Country:US
Mailing Address - Phone:540-443-3832
Mailing Address - Fax:540-443-9362
Practice Address - Street 1:120 PROFESSIONAL PARK DR SE STE 7
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060
Practice Address - Country:US
Practice Address - Phone:540-443-3832
Practice Address - Fax:540-443-9362
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102202357208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1184803330Medicaid
P00754384Medicare PIN
VA1184803330Medicaid