Basic Information
| Provider Information | |||||||||
| NPI: | 1669540894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRATT MEDICAL CENTER,LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRATT HEALTHCARE RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 12101 CAROL LN | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224076101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407857200 | ||||||||
| FaxNumber: | 5407868927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5403453556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101033516 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 211753 | 01 | VA | MAMSI OTHER | OTHER | 5986659 | 01 | VA | AETNA | OTHER | 080024148 | 01 | VA | MEDICARE RAILROAD | OTHER | 2120696 | 01 | VA | MAMSI MRI | OTHER | CA9037 | 01 | VA | MCR RAILROAD GROUP | OTHER | 175407 | 01 | VA | ANTHEM | OTHER | 2102141 | 01 | VA | AETNA HMO | OTHER |