Provider Demographics
NPI:1033141502
Name:BLUE RIDGE ORTHOPAEDIC ASSOC PA
Entity Type:Organization
Organization Name:BLUE RIDGE ORTHOPAEDIC ASSOC PA
Other - Org Name:BLUE RIDGE ORTHOPAEDICS
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-482-6165
Mailing Address - Street 1:10630 CLEMSON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-4545
Mailing Address - Country:US
Mailing Address - Phone:864-482-6000
Mailing Address - Fax:
Practice Address - Street 1:10630 CLEMSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4546
Practice Address - Country:US
Practice Address - Phone:864-482-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA4584Medicaid
SC2348Medicare PIN
SC0134800004Medicare NSC