Provider Demographics
NPI:1023010311
Name:BLUE RIDGE SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:BLUE RIDGE SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:4240 BLUE RIDGE BLVD
Mailing Address - Street 2:SUITE 950
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64133-1713
Mailing Address - Country:US
Mailing Address - Phone:816-358-9990
Mailing Address - Fax:
Practice Address - Street 1:4240 BLUE RIDGE BLVD
Practice Address - Street 2:STE 950
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64133-1755
Practice Address - Country:US
Practice Address - Phone:816-358-9990
Practice Address - Fax:816-358-1608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO130-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506099100Medicaid
P00082928OtherRR MEDICARE