Healthcare Provider Details

I. General information

NPI: 1144924127
Provider Name (Legal Business Name): THOMAS JORDAN O'NEIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 S MAIN ST STE 201
ROCKY MOUNT VA
24151-1767
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-484-4800
  • Fax: 540-484-4847
Mailing address:
  • Phone: 540-224-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102209962
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: