Healthcare Provider Details

I. General information

NPI: 1407823693
Provider Name (Legal Business Name): ELEANOR SUE CANTRELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 ROBERTS AVE SW
WISE VA
24293-5800
US

IV. Provider business mailing address

134 ROBERTS AVE SW
WISE VA
24293-5800
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-8000
  • Fax: 276-376-1020
Mailing address:
  • Phone: 276-328-8000
  • Fax: 276-376-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101036912
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number0101036912
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: