Basic Information
| Provider Information | |||||||||
| NPI: | 1538152913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARILION NEW RIVER VALLEY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARILION CLINIC HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 1006 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245715 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 RANDOLPH ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | RADFORD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241413047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402244753 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR SPR | ||||||||
| AuthorizedOfficialTelephone: | 5402245715 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARILION NEW RIVER VALLEY MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | EXEMPT | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 221349 | 01 | VA | SOUTHERN HEALTH | OTHER | 227173 | 01 | VA | ANTHEM | OTHER | 004915071 | 05 | VA | MEDICAID | 491507 | 01 | VA | MEDICARE PTAN | OTHER |