1639190846 NPI number — BLUE RIDGE NEUROLOGY ASSOCIATES P.C.

Table of content: (NPI 1639190846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639190846 NPI number — BLUE RIDGE NEUROLOGY ASSOCIATES P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE NEUROLOGY ASSOCIATES P.C.
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:
1639190846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2012 BROOKSIDE DR
Provider Second Line Business Mailing Address:
STE. 8
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-4645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-224-4183
Provider Business Mailing Address Fax Number:
423-224-4180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2012 BROOKSIDE DR
Provider Second Line Business Practice Location Address:
STE. 8
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-4183
Provider Business Practice Location Address Fax Number:
423-224-4180
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEW
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
423-224-4183

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD26480 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: MD20022 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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