MEDICARE: ROANOKE PHYSICIAN SERVICES, LLC

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	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1427569524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROANOKE PHYSICIAN SERVICES, LLC

Provider Business Mailing Address
First Line	:	5665 NEW NORTHSIDE DR STE 320
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-5834
Country	:	US
Telephone Number	:	770-874-5400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2706 OGDEN RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-0600
Country	:	US
Telephone Number	:	540-776-4000
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	LISA ROSE MURRAY
Credential	:
Telephone Number	:	770-874-5439

Provider Enumeration Date	:	10/16/2017
Last Update Date	:	10/16/2017

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