Provider Demographics
NPI:1336184084
Name:ROANOKE NEUROSURGERY, LLC
Entity Type:Organization
Organization Name:ROANOKE NEUROSURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:BUDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-772-3527
Mailing Address - Street 1:2766 ELECTRIC RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3583
Mailing Address - Country:US
Mailing Address - Phone:540-989-6516
Mailing Address - Fax:540-989-6516
Practice Address - Street 1:2766 ELECTRIC RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3583
Practice Address - Country:US
Practice Address - Phone:540-989-6516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB1008OtherRR MEDICARE
VA1336184084Medicaid
VAC08865Medicare PIN