Basic Information
| Provider Information | |||||||||
| NPI: | 1720035959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROYAL OAK MEDICAL ASSOCIATES PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SMYTH COUNTY FAMILY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1046 TERRACE DR | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767838123 | ||||||||
| FaxNumber: | 2767832879 | ||||||||
| Practice Location | |||||||||
| Address1: | 1046 TERRACE DR | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767838123 | ||||||||
| FaxNumber: | 2767832879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCDOWELL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2767838123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROYAL OAK MEDICAL ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 240901 | 01 | VA | ANTHEM GROUP | OTHER | CD6056 | 01 | VA | RR MEDICARE | OTHER |