Provider Demographics
NPI:1316919210
Name:LEWIS-GALE PHYSICIANS, LLC
Entity type:Organization
Organization Name:LEWIS-GALE PHYSICIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-772-3672
Mailing Address - Street 1:5303B INDIAN GRAVE RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-6607
Mailing Address - Country:US
Mailing Address - Phone:540-725-3060
Mailing Address - Fax:540-772-4948
Practice Address - Street 1:5303B INDIAN GRAVE RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-6607
Practice Address - Country:US
Practice Address - Phone:540-725-3060
Practice Address - Fax:540-772-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty