Provider Demographics
NPI:1336330620
Name:BLUE RIDGE FOOTCARE AND SURGERY PLC
Entity Type:Organization
Organization Name:BLUE RIDGE FOOTCARE AND SURGERY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:MCKEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:540-885-8891
Mailing Address - Street 1:111 FAIRWAY LN
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-3563
Mailing Address - Country:US
Mailing Address - Phone:540-885-8891
Mailing Address - Fax:540-885-0016
Practice Address - Street 1:111 FAIRWAY LN
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-3563
Practice Address - Country:US
Practice Address - Phone:540-885-8891
Practice Address - Fax:540-885-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300877213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADG6187OtherMEDICARE RR GROUIP
VA1336330620OtherNPI GROUP
VA1588847982OtherNPI GROUP
VA1336330620Medicaid
VA6011470001Medicare NSC
VAP00444411Medicare PIN
VA1336330620OtherNPI GROUP
VAC10346Medicare PIN
VAT21532Medicare UPIN
VA6011470002Medicare NSC