Basic Information
| Provider Information | |||||||||
| NPI: | 1336215367 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL THERAPIES OF ROANOKE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CORA PHYSICAL THERAPY - BLACKSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 SHAWNEE ROAD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192216717 | ||||||||
| FaxNumber: | 4192220507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1995 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 801 | ||||||||
| City: | BLACKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409512703 | ||||||||
| FaxNumber: | 5409530873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 12/04/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/08/2019 | ||||||||
| NPIReactivationDate: | 11/27/2019 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROUSH | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4192216712 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 192427 | 01 | VA | ANTHEM BCBS | OTHER | 29043 | 01 | VA | SOUTHERN HEALTH | OTHER |