Healthcare Provider Details

I. General information

NPI: 1649968223
Provider Name (Legal Business Name): BRAIN INJURY SERVICES OF SWVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 11/06/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3904 FRANKLIN RD SW STE B
ROANOKE VA
24014-3039
US

IV. Provider business mailing address

3904 FRANKLIN RD SW STE B
ROANOKE VA
24014-3039
US

V. Phone/Fax

Practice location:
  • Phone: 540-344-1200
  • Fax:
Mailing address:
  • Phone: 540-344-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: JODI JUDGE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 540-344-1200