MEDICARE: DR. WILLEM ALBERT JOHAN ROELOFSEN IV D.C.

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	111N00000X	Chiropractor	0104000604	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0638226001	OTHER	VA	CIGNA HEALTHCARE
2	7147395	OTHER	VA	AETNA
3	453587	OTHER	VA	BC/BS

General Provider Information

NPI Number	:	1811946452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLEM ALBERT JOHAN ROELOFSEN IV D.C.

Provider Business Mailing Address
First Line	:	1231 MAPLE AVE SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24016-4707
Country	:	US
Telephone Number	:	540-342-9445
Fax Number	:	540-342-9446

Provider Business Practice Location Address
First Line	:	1231 MAPLE AVE SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24016-4707
Country	:	US
Telephone Number	:	540-342-9445
Fax Number	:	540-342-9446

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

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/08/2007

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