Provider Demographics
NPI:1043531288
Name:BLUE RIDGE ENDOCRINOLOGY AND DIABETES PLC
Entity Type:Organization
Organization Name:BLUE RIDGE ENDOCRINOLOGY AND DIABETES PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-293-7811
Mailing Address - Street 1:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-1583
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:199 SPOTNAP RD
Practice Address - Street 2:SUITE 2
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8827
Practice Address - Country:US
Practice Address - Phone:434-293-7811
Practice Address - Fax:434-293-7818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA101936Medicare PIN