Provider Demographics
NPI:1568754489
Name:BLUE RIDGE ORTHOPAEDIC ASSOCIATES
Entity Type:Organization
Organization Name:BLUE RIDGE ORTHOPAEDIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
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:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62063956133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T62063956Medicare PIN