Provider Demographics
NPI:1679905467
Name:PERFORMANCE MEDICINE OF SOUTHWEST
Entity type:Organization
Organization Name:PERFORMANCE MEDICINE OF SOUTHWEST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DELMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-772-1890
Mailing Address - Street 1:25 W CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3836
Mailing Address - Country:US
Mailing Address - Phone:540-772-1890
Mailing Address - Fax:540-772-1893
Practice Address - Street 1:25 W CALHOUN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3836
Practice Address - Country:US
Practice Address - Phone:540-772-1890
Practice Address - Fax:540-772-1893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty