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General NPI Number Information
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NPI Number | 1720513278
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Entity Type | Organization
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Legal Business Name | NEUROSERVICE OF VIRGINIA PC
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Dates
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Enumeration Date | 04/21/2017
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Last Update Date | 04/21/2017
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Provider Practice Location Address
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Address Line | 11533 BUSY ST PMB #306
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23236-4073
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Country | US
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Telephone | 804-220-4643
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Fax |
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Provider Business Mailing Address
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Address Line | 11533 BUSY ST PMB #306
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23236-4073
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THOMAS RALEY
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Credential | M.D.
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Telephone | 804-220-4643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204R00000X
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Taxonomy Name | Electrodiagnostic Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 246ZE0600X
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Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number |
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License Number State |
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