Provider Demographics
NPI:1861453078
Name:BLUE RIDGE ACADEMIC MEDICAL GROUP, PLC
Entity Type:Organization
Organization Name:BLUE RIDGE ACADEMIC MEDICAL GROUP, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIRSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:540-818-5890
Mailing Address - Street 1:2265 KRAFT DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6360
Mailing Address - Country:US
Mailing Address - Phone:540-818-5891
Mailing Address - Fax:
Practice Address - Street 1:3700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7017
Practice Address - Country:US
Practice Address - Phone:540-951-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201473204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA279560OtherANTHEM
VADA5070OtherRAILROAD MEDICARE
VADA5070OtherRAILROAD MEDICARE
VA279560OtherANTHEM