Healthcare Provider Details

I. General information

NPI: 1326048380
Provider Name (Legal Business Name): ERIC MELLENCAMP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 02/08/2019
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

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7037
  • Fax:
Mailing address:
  • Phone: 540-981-7037
  • Fax: 540-342-1757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD040130E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC10006375
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC1-0006375
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD040130E
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101243089
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: