Basic Information
| Provider Information | |||||||||
| NPI: | 1184803330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLIVER | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 PROFESSIONAL PARK DR SE STE 7 | ||||||||
| Address2: | |||||||||
| City: | BLACKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240606739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404433832 | ||||||||
| FaxNumber: | 5404439362 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 PROFESSIONAL PARK DR SE STE 7 | ||||||||
| Address2: | |||||||||
| City: | BLACKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404433832 | ||||||||
| FaxNumber: | 5404439362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 05/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 0102202357 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1184803330 | 05 | VA | MEDICAID |