=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598848848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEAD ADN NECK MEDICINE AND SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 HIGHLAND AVE SE SUITE 104
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24013-2256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-343-4423
-----------------------------------------------------
Fax | 540-343-0495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 HIGHLAND AVE SE SUITE 104
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24013-2256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-343-4423
-----------------------------------------------------
Fax | 540-343-0495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | WILLIAM J DICHTEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 540-343-4423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101040423
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------