Healthcare Provider Details

I. General information

NPI: 1720513278
Provider Name (Legal Business Name): NEUROSERVICE OF VIRGINIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11533 BUSY ST PMB #306
NORTH CHESTERFIELD VA
23236-4073
US

IV. Provider business mailing address

11533 BUSY ST PMB #306
NORTH CHESTERFIELD VA
23236-4073
US

V. Phone/Fax

Practice location:
  • Phone: 804-220-4643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS RALEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 804-220-4643