Provider Demographics
NPI:1447545751
Name:COLLIVER SPORTS & SPINE INC
Entity type:Organization
Organization Name:COLLIVER SPORTS & SPINE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:COLLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:540-553-4587
Mailing Address - Street 1:120 PROFESSIONAL PARK DR SE STE 7
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6739
Mailing Address - Country:US
Mailing Address - Phone:540-443-3832
Mailing Address - Fax:540-443-9362
Practice Address - Street 1:120 PROFESSIONAL PARK DR SE STE 7
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6739
Practice Address - Country:US
Practice Address - Phone:540-443-3832
Practice Address - Fax:540-443-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty