Basic Information
| Provider Information | |||||||||
| NPI: | 1700839958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARILION EMERGENCY SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2080 | ||||||||
| Address2: | |||||||||
| City: | KILMARNOCK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224822080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044353508 | ||||||||
| FaxNumber: | 8044359110 | ||||||||
| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | EMERGENCY DEPT. | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5408530824 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104471 | 01 | VA | ANTHEM GROUP # | OTHER |