Provider Demographics
NPI:1639243850
Name:BLUE RIDGE PAIN TREATMENT CTRS
Entity Type:Organization
Organization Name:BLUE RIDGE PAIN TREATMENT CTRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAIN MANAGEMENT AND ANESTHEOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EH
Authorized Official - Last Name:SHERRY
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:540-801-8804
Mailing Address - Street 1:2034 PRO POINTE LN
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-8021
Mailing Address - Country:US
Mailing Address - Phone:540-801-8804
Mailing Address - Fax:540-801-8828
Practice Address - Street 1:2034 PRO POINTE LN
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-8021
Practice Address - Country:US
Practice Address - Phone:540-801-8804
Practice Address - Fax:540-801-8828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059231305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005710898Medicaid
VA005710898Medicaid
VA003668B81Medicare ID - Type Unspecified