Healthcare Provider Details

I. General information

NPI: 1447545751
Provider Name (Legal Business Name): COLLIVER SPORTS & SPINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PROFESSIONAL PARK DR SE STE 7
BLACKSBURG VA
24060-6739
US

IV. Provider business mailing address

120 PROFESSIONAL PARK DR SE STE 7
BLACKSBURG VA
24060-6739
US

V. Phone/Fax

Practice location:
  • Phone: 540-443-3832
  • Fax: 540-443-9362
Mailing address:
  • Phone: 540-443-3832
  • Fax: 540-443-9362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ETHAN B COLLIVER
Title or Position: PRESIDENT
Credential: DO
Phone: 540-553-4587