Provider Demographics
NPI:1881704997
Name:ROANOKE VALLEY HEALTH SERVICES INC
Entity type:Organization
Organization Name:ROANOKE VALLEY HEALTH SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-535-1398
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:2053 RIVER RD
Mailing Address - City:HENRICO
Mailing Address - State:NC
Mailing Address - Zip Code:27842-0392
Mailing Address - Country:US
Mailing Address - Phone:252-537-9400
Mailing Address - Fax:252-537-1221
Practice Address - Street 1:2053 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:NC
Practice Address - Zip Code:27842-0392
Practice Address - Country:US
Practice Address - Phone:252-537-9400
Practice Address - Fax:252-537-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC348933AMedicaid
NC348933AMedicaid
NC2580318Medicare PIN