Provider Demographics
NPI:1821030461
Name:BLUE RIDGE DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:BLUE RIDGE DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-949-5470
Mailing Address - Street 1:1151 13TH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-4432
Mailing Address - Country:US
Mailing Address - Phone:540-949-6934
Mailing Address - Fax:540-932-7118
Practice Address - Street 1:1151 13TH ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-4432
Practice Address - Country:US
Practice Address - Phone:540-949-6934
Practice Address - Fax:540-932-7118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028429174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA111868OtherANTHEM BC/BS
VA099634OtherANTHEM BC/BS
C14906Medicare PIN
VA111868OtherANTHEM BC/BS