Basic Information
Provider Information | |||||||||
NPI: | 1225105497 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRATT CARDIAC DIAGNOSTIC CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRATT HEALTHCARE CARDIAC DIAGNOSTIC CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8310 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240140310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403453556 | ||||||||
FaxNumber: | 5403422193 | ||||||||
Practice Location | |||||||||
Address1: | 1451 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224018424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403685384 | ||||||||
FaxNumber: | 5403743292 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2006 | ||||||||
LastUpdateDate: | 06/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALKER | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5403453556 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | 0101018510 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
ID | Type | State | Issuer | Description | 237341 | 01 | VA | ANTHEM | OTHER | 080024148 | 01 | VA | MEDICARE RAILROAD | OTHER | 7277516 | 01 | VA | AETNA NON HMO | OTHER | CA9037 | 01 | VA | MCR RAILROAD GROUP | OTHER | 211753 | 01 | VA | MAMSI | OTHER | 3409592 | 01 | VA | AETNA HMO | OTHER | C02375 | 01 | VA | MEDICARE GROUP | OTHER |