Basic Information
Provider Information | |||||||||
NPI: | 1306002431 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEAMON | ||||||||
FirstName: | JESSE | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 RIVERSIDE CIR | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240164955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407251226 | ||||||||
FaxNumber: | 5408575306 | ||||||||
Practice Location | |||||||||
Address1: | 3 RIVERSIDE CIR | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240164955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407251226 | ||||||||
FaxNumber: | 5408575306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2008 | ||||||||
LastUpdateDate: | 12/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | 2014008614 | MO | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XX0801X | 0101042429 | VA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | 0101257741 | VA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1306002431 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | 1306002431 | 01 | VA | UNITED HEALTHCARE | OTHER | 540506332108 | 01 | VA | TRICARE | OTHER | 1306002431 | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | 1306002431 | 01 | VA | GATEWAY | OTHER | 1306002431 | 01 | VA | HEALTHKEEPERS | OTHER | 1306002431 | 01 | VA | HEALTHKEEPERS PLUS | OTHER | 1306002431 | 01 | VA | INTOTAL | OTHER | 1306002431 | 01 | VA | UMWA | OTHER | 1306002431 | 01 | VA | SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY | OTHER | 1306002431 | 01 | VA | AETNA | OTHER | 1306002431 | 01 | VA | VIRGINIA PREMIER | OTHER | 1306002431 | 01 | VA | MEDICAID | OTHER | P01544661 | 01 | VA | RAILROAD MEDICARE | OTHER | 1306002431 | 01 | VA | HUMANA MEDICARE | OTHER | 1306002431 | 01 | VA | ANTHEM BCBS | OTHER | 1306002431 | 01 | VA | CIGNA | OTHER |