=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194783092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT MOORE PICKRAL & DAVID A ELLINGTON PTRS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2006
-----------------------------------------------------
Last Update Date | 06/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 S MAIN ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24450-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-463-9158
-----------------------------------------------------
Fax | 540-463-4218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 146 S MAIN ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24450-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-463-9158
-----------------------------------------------------
Fax | 540-463-4218
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROBERT M PICKRAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 540-463-9158
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 0101036661
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------