MEDICARE: VIRGINIA NEUROSPINE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	0101250836	VA

General Provider Information

NPI Number	:	1356893879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRGINIA NEUROSPINE PC

Provider Business Mailing Address
First Line	:	1019A VISTA PARK DR
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-4901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1019A VISTA PARK DR
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-4901
Country	:	US
Telephone Number	:	434-200-9009
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DIALNTHA ELLEGALA
Credential	:	MD
Telephone Number	:	434-200-9009

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	11/01/2016

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