Basic Information
| Provider Information | |||||||||
| NPI: | 1023108750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH ROANOKE REHAB MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4127 | ||||||||
| Address2: | NORTH ROANOKE REHAB MEDICINE PC | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403449781 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Practice Location | |||||||||
| Address1: | 5720 WILLIAMSON RD | ||||||||
| Address2: | STE 107 NORTH ROANOKE REHAB MEDICINE PC | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402656710 | ||||||||
| FaxNumber: | 5402656712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | AE-SIK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5402656710 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.