Provider Demographics
NPI:1558550301
Name:FAMILY MEDICINE OF BLACKSBURG, LLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE OF BLACKSBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP VP/AO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-3375
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:1645 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-2554
Practice Address - Country:US
Practice Address - Phone:540-552-1246
Practice Address - Fax:540-552-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty