Healthcare Provider Details

I. General information

NPI: 1922452846
Provider Name (Legal Business Name): SAMI BAWALSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

6315 BOULDER TRAIL DR APT 306-1
ROANOKE VA
24019-1918
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7000
  • Fax:
Mailing address:
  • Phone: 540-855-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number011602909
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: