1194746289 NPI number — BLUE RIDGE UROLOGICAL ASSOC., PC

Table of content: (NPI 1194746289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194746289 NPI number — BLUE RIDGE UROLOGICAL ASSOC., PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE UROLOGICAL ASSOC., PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194746289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-0310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-345-3556
Provider Business Mailing Address Fax Number:
540-342-2193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 MEDICAL CENTER CIR
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
FISHERSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22939-2273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-345-3556
Provider Business Practice Location Address Fax Number:
540-342-2193
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUCKLEY
Authorized Official First Name:
CARIE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
540-345-3556

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  0101033256 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 049990 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 279040 . This is a "ANTHEM" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 011346 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 011345 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 440822 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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