Basic Information
Provider Information | |||||||||
NPI: | 1881927259 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACV INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13306 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240323306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403450289 | ||||||||
FaxNumber: | 5403459569 | ||||||||
Practice Location | |||||||||
Address1: | 5115 BERNARD DR | ||||||||
Address2: | SUITE 201 | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240184357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403450289 | ||||||||
FaxNumber: | 5403459569 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2009 | ||||||||
LastUpdateDate: | 07/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEARSON | ||||||||
AuthorizedOfficialFirstName: | THEODORE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5403450289 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 07/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | C10909 | 01 | VA | GROUP MEDICARE # | OTHER |