Provider Demographics
NPI:1518118330
Name:BLUE RIDGE PAIN MANAGEMENT ASSOCIATES, PC
Entity Type:Organization
Organization Name:BLUE RIDGE PAIN MANAGEMENT ASSOCIATES, PC
Other - Org Name:BAYLOR PAIN MANAGEMENT, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DRAGOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-444-5670
Mailing Address - Street 1:100 KNOTBREAK RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-5414
Mailing Address - Country:US
Mailing Address - Phone:540-444-5670
Mailing Address - Fax:540-444-5669
Practice Address - Street 1:100 KNOTBREAK RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-444-5670
Practice Address - Fax:540-444-5669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGC1126Medicare PIN
VA7429340001Medicare PIN