Healthcare Provider Details

I. General information

NPI: 1609895267
Provider Name (Legal Business Name): ROANOKE EAR NOSE & THROAT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MCCLANAHAN ST SW
ROANOKE VA
24014-1709
US

IV. Provider business mailing address

PO BOX 8788
ROANOKE VA
24014-0736
US

V. Phone/Fax

Practice location:
  • Phone: 540-345-3556
  • Fax: 540-342-2193
Mailing address:
  • Phone: 540-345-3556
  • Fax: 540-342-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number0101044826
License Number StateVA

VIII. Authorized Official

Name: GEOFFREY T HARTER
Title or Position: PRESIDENT
Credential: MD
Phone: 540-345-3556