Provider Demographics
NPI:1558557090
Name:BLUE RIDGE INTERNAL MEDICINE INC.
Entity Type:Organization
Organization Name:BLUE RIDGE INTERNAL MEDICINE INC.
Other - Org Name:BLUE RIDGE INTERNAL MEDICINE LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACINDA
Authorized Official - Middle Name:SANTON
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-487-0232
Mailing Address - Street 1:PO BOX 5065
Mailing Address - Street 2:407 12TH STREET EXTENSION
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-5065
Mailing Address - Country:US
Mailing Address - Phone:304-487-0232
Mailing Address - Fax:304-487-0285
Practice Address - Street 1:407 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2300
Practice Address - Country:US
Practice Address - Phone:304-487-0232
Practice Address - Fax:304-487-0285
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE RIDGE INTERNAL MEDICINE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-19
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1804291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory