Provider Demographics
NPI:1043240278
Name:BLUE RIDGE EYE ASSOCIATES PC
Entity Type:Organization
Organization Name:BLUE RIDGE EYE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:540-463-9350
Mailing Address - Street 1:30 CROSSING LANE
Mailing Address - Street 2:STE. 107
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-6354
Mailing Address - Country:US
Mailing Address - Phone:540-463-9350
Mailing Address - Fax:540-463-1722
Practice Address - Street 1:30 CROSSING LANE
Practice Address - Street 2:STE. 107
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-6354
Practice Address - Country:US
Practice Address - Phone:540-463-9350
Practice Address - Fax:540-463-1722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA108018OtherANTHEM BCBS
VA009235728Medicaid
VA08996200000OtherSOUTHERN HEALTH
VA108018OtherANTHEM BCBS
VA410000804Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
VA009235728Medicaid
VAC09991Medicare PIN