Provider Demographics
NPI:1538152913
Name:CARILION NEW RIVER VALLEY MEDICAL CENTER
Entity type:Organization
Organization Name:CARILION NEW RIVER VALLEY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONAL SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-224-5352
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:701 RANDOLPH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-3047
Practice Address - Country:US
Practice Address - Phone:540-224-4753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARILION NEW RIVER VALLEY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-31
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
EXEMPT251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004915071Medicaid
VA491507OtherMEDICARE PTAN
VA227173OtherANTHEM
VA221349OtherSOUTHERN HEALTH
VA=========010OtherTRICARE