Healthcare Provider Details

I. General information

NPI: 1689699712
Provider Name (Legal Business Name): MELANIE K PRUSAKOWSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE CARILION ROANOKE MEMORIAL HOSPITAL PEDS ED
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

1 RIVERSIDE CIR 4TH FLOOR, ED ADMINISTRATION
ROANOKE VA
24016-4961
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-8919
  • Fax:
Mailing address:
  • Phone: 540-597-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101243116
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number0101243116
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: