Basic Information
Provider Information | |||||||||
NPI: | 1912987231 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARILION TAZEWELL COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARILION HOME CARE SERVICES TAZEWELL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 141 BEN BOLT AVENUE | ||||||||
Address2: |   | ||||||||
City: | TAZEWELL | ||||||||
State: | VA | ||||||||
PostalCode: | 24651 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2769888714 | ||||||||
FaxNumber: | 2769888708 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2006 | ||||||||
LastUpdateDate: | 08/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNTER | ||||||||
AuthorizedOfficialFirstName: | REBECCA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR SPR | ||||||||
AuthorizedOfficialTelephone: | 5402245715 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC | ||||||||
NPICertificationDate: | 08/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 1360556 | 01 |   | UMWA | OTHER | 733963 | 01 |   | US DEPT OF LABOR | OTHER | 4970187 | 05 | VA |   | MEDICAID | 740027 | 01 | VA | ANTHEM BCBS | OTHER |