1043240278 NPI number — BLUE RIDGE EYE ASSOCIATES PC

Table of content: (NPI 1043240278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043240278 NPI number — BLUE RIDGE EYE ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE EYE ASSOCIATES 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:
1043240278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 CROSSING LANE
Provider Second Line Business Mailing Address:
STE. 107
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24450-6354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-463-9350
Provider Business Mailing Address Fax Number:
540-463-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 CROSSING LANE
Provider Second Line Business Practice Location Address:
STE. 107
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24450-6354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-463-9350
Provider Business Practice Location Address Fax Number:
540-463-1722
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUDSON
Authorized Official First Name:
MARC
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-463-9350

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000318 , 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: 108018 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 009235728 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08996200000 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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