Healthcare Provider Details

I. General information

NPI: 1255413027
Provider Name (Legal Business Name): LEWIS-GALE PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 S JEFFERSON ST
ROANOKE VA
24016-4705
US

IV. Provider business mailing address

1231 S JEFFERSON ST
ROANOKE VA
24016-4705
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2957
  • Fax: 540-981-0954
Mailing address:
  • Phone: 540-982-2957
  • Fax: 540-981-0954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number0101026794
License Number StateVA

VIII. Authorized Official

Name: OTIS BLACKWOOD
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 540-772-5992