MEDICARE: DR. JANINE MARIE TALTY D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	20A6830	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0102202736	OTHER	VA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1396873774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANINE MARIE TALTY D.O.

Provider Business Mailing Address
First Line	:	2702 BRAMBLETON AVE SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24015-4308
Country	:	US
Telephone Number	:	540-685-2670
Fax Number	:	540-685-2671

Provider Business Practice Location Address
First Line	:	2702 BRAMBLETON AVE SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24015-4308
Country	:	US
Telephone Number	:	540-685-2670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/16/2019

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