Provider Demographics
NPI:1639232234
Name:BLUE RIDGE ORTHOPAEDICS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BLUE RIDGE ORTHOPAEDICS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CODING COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:ALETHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUTTALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-347-9298
Mailing Address - Street 1:52 W SHIRLEY AVE BLDG B
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 BLDG B
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:2006-12-18
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C00617Medicare PIN