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General NPI Number Information
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NPI Number | 1497957419
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Entity Type | Organization
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Legal Business Name | GILL MEMORIAL ENT CLINIC, PC
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Dates
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Enumeration Date | 06/01/2007
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Last Update Date | 07/30/2007
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Provider Practice Location Address
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Address Line | 707 S JEFFERSON ST FL 5
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City | ROANOKE
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State | VA
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Zip | 24016-5100
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Country | US
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Telephone | 540-344-2071
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Fax | 540-982-8490
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Provider Business Mailing Address
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Address Line | 707 S JEFFERSON ST FL 5
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City | ROANOKE
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State | VA
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Zip | 24016-5100
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Country | US
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Telephone | 540-344-2071
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Fax | 540-982-8490
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK R HANABURY JR.
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Credential | M.D.
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Telephone | 540-344-2071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0101031266
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License Number State | VA
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