Healthcare Provider Details

I. General information

NPI: 1659350908
Provider Name (Legal Business Name): HERBERT WHITLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2006
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HIGHLAND AVE SE
ROANOKE VA
24013-2255
US

IV. Provider business mailing address

1928 SPRINGMILL RD
SALEM VA
24153-4703
US

V. Phone/Fax

Practice location:
  • Phone: 540-224-4545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number0101-231079
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: