Healthcare Provider Details

I. General information

NPI: 1629713391
Provider Name (Legal Business Name): EDDIE CHARLES GEORGE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

IV. Provider business mailing address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2463
  • Fax:
Mailing address:
  • Phone: 540-982-2463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009163
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: