MEDICARE: ROANOKE FAMILY PRACTICE

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	261Q00000X	Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DO2435	OTHER		RAILROAD MEDICARE PIN

General Provider Information

NPI Number	:	1518119023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROANOKE FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	902B ROANOKE AVE
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-5565
Country	:	US
Telephone Number	:	252-384-0154
Fax Number	:	252-335-2731

Provider Business Practice Location Address
First Line	:	902B ROANOKE AVE
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-5565
Country	:	US
Telephone Number	:	252-384-0154
Fax Number	:	252-335-2731

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. DEBRA LYNN BOWMAN
Credential	:
Telephone Number	:	252-384-0154

Provider Enumeration Date	:	10/15/2008
Last Update Date	:	05/11/2010

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Directions to “ROANOKE FAMILY PRACTICE ” Practice Location

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