Healthcare Provider Details

I. General information

NPI: 1306170048
Provider Name (Legal Business Name): RONCEVERTE PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 MAPLEWOOD AVE
RONCEVERTE WV
24970-1334
US

IV. Provider business mailing address

7100 COMMERCE WAY SUITE 180
BRENTWOOD TN
37027-2851
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-4411
  • Fax:
Mailing address:
  • Phone: 877-892-9813
  • Fax: 615-465-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR
Credential:
Phone: 877-892-9813