Healthcare Provider Details

I. General information

NPI: 1760158208
Provider Name (Legal Business Name): ROANOKE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 DENNISTON AVE SW
ROANOKE VA
24015-2023
US

IV. Provider business mailing address

1901 DENNISTON AVE SW
ROANOKE VA
24015-2023
US

V. Phone/Fax

Practice location:
  • Phone: 540-613-8565
  • Fax:
Mailing address:
  • Phone: 540-613-8565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MATHEW HENDERSON
Title or Position: OWNER
Credential: DO
Phone: 540-613-8565