Provider Demographics
NPI:1508959701
Name:BLUE RIDGE ORTHOPAEDIC ASSOCIATES PC
Entity Type:Organization
Organization Name:BLUE RIDGE ORTHOPAEDIC ASSOCIATES PC
Other - Org Name:BLUE RIDGE ORTHOPAEDIC & SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:540-347-9220
Mailing Address - Street 1:52 W. SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-3008
Mailing Address - Country:US
Mailing Address - Phone:540-347-9220
Mailing Address - Fax:540-347-0492
Practice Address - Street 1:52 W. SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3008
Practice Address - Country:US
Practice Address - Phone:540-347-9220
Practice Address - Fax:540-347-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 208100000X
C00617207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0275680001Medicare NSC
VAC00617Medicare PIN
C00617Medicare UPIN