Healthcare Provider Details

I. General information

NPI: 1205258829
Provider Name (Legal Business Name): ROANOKE ADULT MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 CLAY ST SE
ROANOKE VA
24013-2105
US

IV. Provider business mailing address

1708 CLAY ST SE
ROANOKE VA
24013-2105
US

V. Phone/Fax

Practice location:
  • Phone: 540-309-7569
  • Fax:
Mailing address:
  • Phone: 540-309-7569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number0101024791
License Number StateVA

VIII. Authorized Official

Name: WILLIAM C WARD
Title or Position: PRESIDENT
Credential: MD
Phone: 540-309-5769